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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Vytorin for treatment of the enrollees cholesterolemia. Findings:  The physician reviewer found that Vytorin contains a combination of ezetimibe and simvastatin. Currently, there is a lack of data in the peer-reviewed medical literature supporting the use of brand name Vytorin over the generic versions. This patient states intolerance to the generic and some notes state allergy. However, there are no specific dates or medical records documenting specific outcomes with use of generic versions demonstrating intolerance. All told, this patients records do not support the medical necessity of the requested brand name Vytorin. 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 internal medicine with sub-specialty certification in 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a scooter (power operated vehicle) and ramp for medical treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, there are no indications that the patients mobility was assessed in detail by her physicians or by a physical or occupational therapist.  There are no objective indications that the patient is unable to manage her basic household mobility by ambulating, using a walker.  There is a lack of documentation of musculoskeletal or cardiovascular impairments that would preclude the use of an optimally fitted manual wheelchair allowing for bimanual propulsion (or bimanual and bipedal propulsion), for accomplishing her mobility related activities of daily living if the walker is insufficient for her mobility needs.  Overall, the records do not establish that the patient would be bed or chair confined without a power mobility device.  Additionally, physical activity is generally appropriate for general musculoskeletal health and for chronic pain syndromes.  All told, the requested scooter (power operated vehicle) and ramp are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-eight year-old female with a history of cirrhosis, Graves disease, and diabetes mellitus is requesting authorization of Xifaxan (rifaximin).Reviewers Findings:  The reviewing physician found that rifaximin is safe and effective in patients with hepatic encephalopathy, and is considered within the standard of care for the management of patients with this condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 22.5 hours per week of direct one-to-one applied behavioral analysis (ABA) therapy for six months. The requested services of 22.5 hours per week of direct ABA therapy are not medically necessary for treatment of the patients medical condition. The patient has been receiving ABA services for at least the past 12 years. Details regarding the number of hours received during that time were not provided. The patient has been documented as having had a significant decline in the frequency of his problematic behaviors, several of which have been extinguished. A medical literature reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors reported that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Another study reached similar conclusions. The Health Plans approved for 65 hours per month (16.25 hours per week) of direct one-to-one ABA services is reasonable given this patients current behavioral issues. Given these findings, the requested 22.5 hours per week of direct ABA therapy is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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 48-year-old female enrollee has requested reimbursement and continued authorization and coverage for transcranial magnetic stimulation (TMS) therapy provided from a specific date and ongoing. Findings:  Three physician reviewers found that the patient was diagnosed with major depressive disorder, recurrent, severe. She presents with depressed mood, anhedonia, tearfulness, guilt, difficulty with focus, problematic sleep, lack of motivation, fatigue and, suicidal ideation. She has impaired functioning socially and occupationally. Of note is that this patient has had two suicide attempts. She has been tried on and failed to achieve significant improvement or remission on multiple antidepressants and augmentation strategies, including: Zoloft, Prozac, Lexapro, Remeron and Lamictal, which have been either ineffective or produced intolerable side effects. Psychotherapeutic approaches and partial hospitalization have also yielded inadequate therapeutic effect. The patient has requested reimbursement and prospective authorization for transcranial magnetic stimulation (TMS) therapy provided from a specific date and ongoing. The Health Plan has denied this request, as investigational.  According to the records provided for review, this patients depression was treatment resistant since multiple antidepressants and augmentation strategies had not successfully brought on remission. In the peer-reviewed studies, Schutter reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for major depressive disorder. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS. A recent report from the New England Comparative Effectiveness Public Advisory Council (CEPAC) indicated that TMS therapy is as good, or better, than usual care and that equivalent or superior outcomes for TMS were found when compared to electroconvulsive therapy. Additionally, Connolly and colleagues reported that TMS was found to be safe and effective in both the acute and maintenance treatment of patients with treatment resistant depression. Thus, TMS is an effective treatment supported by the evidence-based literature. Further, TMS has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant major depressive disorders. Consistent with this support, the TMS therapy provided from the date in question and forward was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested for acupuncture for treatment of his rhinitis.   Findings:  Two physician reviewers found that there are still numerous options and strategies that have not been utilized and are still available. Furthermore, the Practice Parameter for Diagnosis and Management of Rhinitis Complete Guidelines of Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology does not list acupuncture as a treatment option for rhinitis. To date, there is a lack of sufficient evidence to support the use of acupuncture in patients with allergic rhinitis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 30-year-old female enrollee has requested authorization and coverage for atovaquone. The records provided for review document that testing dated 5/3/16 indicated a positive test for the medical condition. However, based on Centers for Disease Control and Prevention (CDC) criteria, a diagnosis must be made with either Wright-Gemsa, DNA in whole blood by nucleic acid amplification, or isolation of whole organism in blood. The testing method in this patients case was an antibody test, which does not meet the CDC criteria for the diagnosis. In addition, the recommended duration of treatment is 7-10 days for patients with the diagnosis. All told, atovaquone is not medically necessary for 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 internal medicine with sub-specialty certification in infectious 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for any or all of the intensive outpatient program (IOP) level of care services provided by Evolve Growth Initiatives. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to recurrent suicidal ideation and urges to self-harm while enrolled in partial hospitalization program (PHP) and IOP. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to academic difficulties and interpersonal conflicts. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the parents separation and the patients reports of being triggered by his mothers drinking. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in treatment and in treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to persistent symptoms despite multiple hospitalizations, two courses of residential treatment, and prior IOP treatment. With regard to treatment acceptance and engagement, the records support a score of 2 due to the patients active participation in treatment. Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. This is consistent with the IOP level of care that the patient received. Therefore, IOP level of care services provided by Evolve Growth Initiatives were medically necessary for the 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 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: Upheld

While in India the patient fell and sustained a C6-C7 fracture with quadriplegia. He was treated at a hospital in India and subsequently developed a decubitus ulcer in the sacrum. The patients family arranged transfer back to the United States via air ambulance. A request has been made for reimbursement from the Health Plan for the transportation costs. At issue is whether the air ambulance services at issue were medically necessary for treatment of the patients condition.The patient had a history of electrolite imbalance and developed a large sacrum ulcer, but the submitted clinical evidence indicates he was stable at the time of transport from India to the United States. There is no evidence that transportation was necessary to obtain essential treatment. Based upon the information provided, the care the patient was provided in India was medically reasonable and appropriate. There is no evidence appropriate care of the patients decubitus ulcer was unavailable in India. Therefore, I have determined that the services at issue were not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive group therapy services three times a week specifically for transitional adults (18-24 years old).The submitted documentation supports that the requested services are medically necessary. Transitional age youth are young people moving from adolescence to young adulthood (ages 18-24). They have stressors that are unique to this age group including: moving away from family, becoming independent, developing ones identity, and learning to handle more complex relationships. For this age group, handling these tasks while adjusting to the start of college can be challenging. Research has shown that without a structured transition process (such as a psychotherapy group for ages 18-24), youth and young adults are more likely to have problems with medical complications, limitations in health and wellbeing, difficulties with treatment and medication adherence, discontinuity of care, and preventable emergency department and hospital use. In this case, the patient was struggling to adjust to college life and was having severe depressive episodes, dissociation, and suicidal ideation. At this time, the patient has severe depression with a recent history of a suicide attempt of high lethality. The patient poses a high risk of decompensation should she be treated in a program that is not specialized to the behavioral needs of her age group. Under these circumstances, the requested intensive group therapy services three times a week specifically for transitional adults (18-24 years old) are medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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: Upheld

A 39-year-old male enrollee has requested Lovaza for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that the patient is undergoing risk reduction for coronary artery disease and vascular disease. He will benefit from LDL lowering, which is not the primary action of Lovaza. However, if there is a specific need for lowering of the patients triglycerides, the alternatives offered by the Health Plan are clinically appropriate medications to use and have been shown to decrease arteriosclerotic vascular disease risk.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old male has requested tongue base suspension for treatment of his severe obstructive sleep apnea.  Findings:  Three physician reviewers found that the patient has severe sleep apnea, which is well documented on his polysomnogram. He is not significantly overweight and does not tolerate treatment with continuous positive airway pressure (CPAP). Endoscopic examination suggests a multi-level obstruction for which uvulopalatopharyngoplasty (UPPP) and tongue suspension has been recommended by the patients provider. The records demonstrate that the severity of the patients sleep apnea warrants aggressive management. Given that the patient is not tolerating CPAP, a benchmark management, and he is not significantly overweight, other measures are indeed indicated. Among the patients alternative treatment options is tracheostomy, which is a more invasive intervention than the proposed treatment. Consistent with these findings, the requested procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Decision DX Melanoma multivariate gene expression assay for the evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch.  Mitotic index has also been thought to add a bit more to the prognostics. By these determinations, this patient has a very low risk of recurrence and would not be considered for adjuvant therapy.  Decision DX is the study of 31 genes in the melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease-free state at five years), or Class 2 (with a 31% disease-free rate at five years).  Per the medical literature, there is good correlation between prognosis and Decision DX classification.  However, it is not clear how Decision DX data compares to the ten-year data of the Balch determinations, and whether it can be used in clinical practice.  This is significant in this patients case, given his excellent prognosis.  All told, the Decision DX Melanoma multivariate gene expression assay was not medically indicated for the evaluation of this patient. 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 internal medicine with sub-specialty certification in medical oncology 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: A patient has requested reimbursement for inpatient rehabilitation services. The Health Plan has denied this request indicating that the requested inpatient rehabilitation services were not medically necessary for treatment of the patients medical condition. The submitted documentation does not support that the services at issue were medically necessary. In this case, the patient sustained multiple injuries to his body and brain as a result of aortic dissection and accompanying stroke. He underwent emergent surgical repair of the dissection and had subsequent sternal precautions. His stroke-related deficits were relatively mild and he recovered significant motor function. The patients hospital course was complicated by urinary retention, which required persistent intermittent catheterization. The patients comorbidities included atrial fibrillation that required anticoagulation and obstructive sleep apnea. Records indicate that the patient stopped using CPAP (Continuous Positive Airway Pressure) therapy at home prior to the hospitalization and that the patient did not tolerate CPAP therapy at the rehabilitation facility. The patient otherwise progressed medically and functionally to the degree that further care could have been provided in the community setting. There are no indications in the patients records that he required ongoing inpatient hospitalization on any skilled nursing or medical issues. Under these circumstances, the acute inpatient rehabilitation services were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested reimbursement for inpatient rehabilitation services 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 physical medicine & rehabilitation 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 parent of a 10-year-old male enrollee has requested a tonsillectomy for treatment of the enrollees stated condition of sleep apnea. Findings:  The physician reviewer found that this patient does not meet current criteria for consideration of surgical removal of his tonsils secondary to obstructive sleep apnea syndrome. For the patient to meet medical necessity criteria for a tonsillectomy due to obstructive sleep apnea syndrome, thorough documentation of his symptoms of obstructive sleep apnea is required. The records submitted only document some tonsil hypertrophy, along with mild symptoms of noisy breathing and snoring with only minimal symptoms related to obstructive sleep disordered breathing. The medical literature supports the contention that patients with a documented positive polysomnogram fair much better with tonsillectomy surgery than those who are observed medically. In this case, polysomnogram results have not been provided. In summary, although many patients with obstructive sleep disordered breathing are significantly improved with tonsillectomy, the medical records submitted in this patients case are insufficient to confirm a diagnosis of obstructive sleep apnea.