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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization psychiatric substance abuse level of care services.  Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate that the patient was cooperative in treatment. The patient had minimal treatment in 2017. On admission to the partial hospitalization program, the patient appeared motivated for treatment and was not experiencing withdrawal symptoms, medical problems, or any serious psychiatric symptoms that required intensive daily treatment. She was motivated for treatment with mention of insight into her illness as well as documentation of her knowledge of skills to maintain sobriety. The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services can assist in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 to 3 due to the loss of custody of her child and continued substance use. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. With regards to level of stress of the recovery environment, the records support a score of 3 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 3 due to lack of treatment during the prior 12 months. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15 to 16. This score correlates with services in a community-based outpatient clinic setting. Thus, the patient could have been treated in a less restrictive setting. In sum, partial hospitalization psychiatric substance abuse level of care services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 54-year-old male enrollee requested atenolol at a quantity of 100 pills per refill for medical treatment of his hypertension.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Based on the records provided, this patient has a history of hypertension on atenolol medication.  In this circumstance, a once yearly follow-up visit is medically appropriate to determine the ongoing safety and efficacy of continuing atenolol medication.  If the patients blood pressure is now under poor control, then medication adjustment may be required.  Routine yearly follow-up for ongoing evaluation and management of hypertension is consistent with current guidelines.  The patients new provider appropriately renewed a limited amount of atenolol medication to allow time for the patient to be reevaluated before he runs out of medication.  All told, atenolol at a quantity of 100 pills per refill is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested genetic testing to rule out non-polyposis colorectal cancer for evaluation of her history of polyps.  Findings:  Three physician reviewers found that the relevant medical literature suggests that there is utility in testing well selected patients without a personal history of colorectal cancer. Jo and colleagues reviewed the association between polyps and family history of colon cancer and showed that over 15% of patients with more than 15 adenomatous polyps not associated with familial adenomatous polyposis had a biallelic MYH mutation. These findings suggested that presentation with polyps may be sufficient reason to proceed with testing. In addition, Beck and colleagues concluded that genetic testing in patients with polyps and a personal or strong family history of cancer is indicated. This case involves a female with a strong cancer history involving both her maternal and paternal lineages, with a personal history of polyps on at least two occasions. As such, if this patient tested positive, she would be a candidate for prophylactic bowel resection to reduce the risk of colon cancer and would be subjected to increased screening for other HNPCC-associated tumors. As noted in this patients genetic consultation, no affected members in either the maternal or paternal line are alive to proceed with testing, save one paternal uncle which would not address any potential risk she may have inherited from her mothers lineage. For these reasons, the patients genetic counselors have adequately demonstrated that this patients case should be viewed as the exception to standard testing guidelines as the collected data is likely to have an impact on decision making regarding her treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an automatic external defibrillator.Findings:  The physician reviewer found that a study in Circulation in 2016 looked at Sudden Death in the Young and found that home AEDs are important for these patients. There have been numerous articles published in journals describing the safety and efficacy of the devices in children. Most pediatric cardiologists recommend that families obtain AEDs for their children with long QT and carry them, as AEDs are not always readily available in public. AEDs have been proven to save lives. Survival is greatest when the AED is placed within three minutes of a witnessed collapse. The goal is to let children have as normal a life as possible without excessive risk. The medical literature stated that prescribing an automated external defibrillator should be considered for children at increased risk of sudden arrhythmic death, especially when the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.In this case, the submitted documentation supports that the requested AED is medically necessary. The patient with long QT syndrome and with multiple episodes of syncope associated with exercise. Although undocumented by EKG, these episodes of syncope may have been due to a potentially life threatening arrhythmia. The patient has a markedly abnormal and prolonged QTc on EKG, which puts her in a higher risk category for sudden death due to an arrhythmia. The patient also has a strong family history of sudden death and possible long QT. An implanted ICD has been discussed with the patient but she is currently not a candidate at this time, as she has not had an aborted episode of sudden death or documented ventricular arrhythmia. An ICD in active patients at this age also carries increased risks of inappropriate shocks and lead fractures. An AED is necessary to be immediately available in the event that the patient does have a life-threatening arrhythmia. Under these circumstances, the requested automatic external defibrillator is medically necessary to treat the patients medical condition.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 subspecialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned

A 36-year-old female enrollee has requested a six foot ultraviolet light therapy system for medical treatment of her atopic dermatitis. Findings:  Three physician reviewers found that according to the medical records, the use of whole-body UV irradiation in this patient was required to get her disease under control during hospitalization. The patient will need to continue UV treatment three times per week indefinitely. Thus, her provider recommended a broadband UVB phototherapy system known to be effective in treating patients with atopic dermatitis. Currently, atopic dermatitis is an indication for UVA/UVB therapy, and home UV light booths or lamps are appropriate for patients who have failed standard therapy. All told, the requested home six foot ultraviolet light system is likely to be more beneficial than any available standard therapy, and has already demonstrated therapeutic efficacy in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male has requested transcranial magnetic stimulation (TMS) therapy for treatment of his depression.  Findings:  Two physician reviewers found that the patient has been diagnosed with major depressive disorder, recurrent, severe. He presented with depressed mood, panic attacks, difficulty concentrating, sleep disruption, loss of appetite and fatigue. The patients symptoms were noted to be affecting his social and occupational functioning. Per the record, the patient has attempted treatment with low dose Doxepin and was briefly treated with Imipramine.  There is ample evidence in the peer reviewed medical literature that TMS is a safe and effective treatment for major depressive disorder and is more likely than sham treatment to be effective in achieving remission in patients diagnosed with treatment resistant depression (George, et al. and Schutter, et al.). The American Psychiatric Association (APA) has indicated that TMS is effective for treating depression, during the acute treatment phase. Additionally, the Food and Drug Administration (FDA) has approved TMS for the treatment of treatment-resistant depression. Although TMS is an effective treatment for depression, it is not considered to be a first-line therapy and should be reserved only for patients with treatment resistant depression. The documentation provided, does not demonstrate the patients depression is treatment resistant, as there is little information regarding whether any adequate course of antidepressant therapy or psychotherapy has been attempted with this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi, Daklinza and Ribavirin for 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the American Association for the Study of Liver Disease/Infectious Diseases Society of America (AASLD/IDSA) guidelines represent the standard of care in this setting. According to the AASLD/IDSA guidelines for the retreatment of persons in whom prior therapy has failed, the following therapy is recommended for patients with HCV genotype 3 infection with cirrhosis in whom prior treatment with Peginterferon and Ribavirin has failed: daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 24 weeks along with weight-based Ribavirin. Since the patient has already failed prior therapy, his only treatment option based on the above nationally-recognized guidelines is the proposed 24-week course of Sovaldi, Daklinza and Ribavirin. As such, the requested medications are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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

The patient is a nine-year-old male with short stature and IGF-1 deficiency.  He participated in a clinical trial and began growth hormone therapy in June of 2004.  Indications for the therapy included short stature, a subnormal rate of growth of 2cm per year, low IGF-1 levels at 52ng/ml and 63ng/ml, low IGFBP-3 levels at 0.83ng/ml and 0.87ng/ml, and a bone age read as 72 months at a chronological age of 99 months. He had normal thyroid function and his growth hormone responses to arginine and GHRH were supra-normal rising to 81.70ng/ml and 91ng/ml. After one year of growth hormone therapy, the patients growth rate has increased to 10cm per year and his IGF-1 level increased to 188ng/ml. The patients initial response to standard doses of GH was minimal and his dosage was increased from 0.8mg to 1.875mg per day (0.73mg/kg/week), to achieve his enhanced growth.  The patients GH (if not IGF-1) therapy should be continued based on the clinical findings outlined above.  He appears likely to have GH insensitivity, which has been overcome by large doses of GH therapy.   If so, he may be a candidate for the IGF-1 therapy recently approved by the FDA, rather than the high dose GH therapy that he is receiving at present. A blood level of IGFBP-1/2 would be diagnostically helpful if found to be elevated in his initial serum samples. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

An female enrollee has requested reimbursement for the coronary computed tomography (CT) angiogram. Findings:  The physician reviewer found that there are no documented symptoms of chest discomfort. A stress echocardiogram on 5/2/12 reported no provocable ischemia. An echocardiogram reported normal left ventricular function. A coronary computed tomography (CT) angiogram revealed a moderate 50-70% stenosis of the left anterior descending coronary artery. The patient has requested reimbursement for the coronary CT angiogram. In this circumstance of an asymptomatic patient guidelines for the assessment and management of coronary risk that are endorsed by several national organizations do not recommend coronary CT angiography. Moreover, if an assessment of coronary anatomy were to be indicated, then conventional coronary angiography is preferred due to improved accuracy and the ability to intervene with coronary revascularization during the same procedure if clinically indicated. All told, the coronary CT angiogram 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 diagnostic procedure at issue was 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: the physician reviewers are certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested an MRI of bilateral breasts for evaluation of the enrollees family history of breast cancer.  Findings:  The physician reviewer found that the guidelines for the use of screening breast MRI are well-established in the medical literature. The American Society of Breast Surgeons recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA1 or BRCA2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of 18.8% of developing breast cancer, which is less than the recommended guideline of 20% calculated lifetime risk.  She has no personal history of radiation to the chest.  Additionally, there is no documentation that a first-degree relative has a BRCA1 or BRCA2 mutation.  At this time, the patient does not meet the established guidelines for a screening breast MRI.  All told, the requested MRI of bilateral breasts is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient met the criteria for RTC level of care services. The patient was at some risk of harm (score 2) given her recent passive suicidal ideation without intent or conscious plan. The patient demonstrated serious functional impairment (score 4) due to her inability to perform ADLs. The patient has no major medical problems (score 1). However, she has OCD, which has manifested in compulsive habits and checking behaviors that have impaired her ability to function. The patients recovery environment was moderately stressful (score 3) considering her marital strife and issues with her spouses alcohol dependence. The patients recovery environment was supportive (score 2) as she lives with her husband and dog. Despite marital strife, the patients husband demonstrated support for the patient. The patient has exhibited poor response to prior treatment (score 4) as the records document failure of IOP as well as a PHP levels of care prior to RTC admission. The patient was positively engaged in treatment (score 2) as her providers described her as adherent with treatment although struggles with the exposure hierarchy. This gives the patient a composite score of 18, which is consistent with high intensity community based services. However, based on her score of 4 for functional status, and 4 for prior to response to treatment, the patient met the requirements for medically monitored residential services, such as RTC. Accordingly, the RTC level of care services were medically necessary for treatment of this patient.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 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 54-year-old female enrollee has requested a vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that while vertical sleeve gastrectomy is gaining support as a primary procedure, it has traditionally been used as a component of a staged procedure in super morbidly obese patients or as a primary procedure in patients with esophageal motility disorders or other contraindications to Roux-en-Y gastric bypass (RYGB) or adjustable gastric banding (Lap-Band). This patients records do not demonstrate any evidence of esophageal dysmotility or other contraindication to RYGB or Lap-Band. The American Society for Metabolic & Bariatric Surgery (ASBMS) indicates that a new position paper is pending, but without further information, the efficacy of sleeve gastrectomy remains unclear. This conclusion is further proven by Tucker and colleagues requirement in their 2008 study for institutional review board (IRB) approval, which suggests this specific procedure is still being studied. This patient should achieve good results with the standard surgical alternatives of RYGB or Lap-Band as suggested by her provider.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for oxycodone/acetaminophen for treatment of the enrollees chronic back pain. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient has tried and failed conservative treatment options including epidural steroid injections for his chronic back pain and sciatica. According to the documents available for review, the patient has demonstrated objective functional improvement on his current regimen without side effects. Moreover, the patient has been appropriately monitored for possible drug aberrant behavior as required for ongoing treatment. Given these findings, the requested oxycodone/acetaminophen is medically necessary for treatment of this 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 anesthesiology with sub-specialty certification 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.