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

The patient is a 24-year-old female with a diagnosis of major depression, recurrent, rule-out bipolar disorder, and concurrent personality disorder  not otherwise specified (predominantly borderline). She was admitted to residential treatment on 4/9/04 due to feeling increasingly depressed. This involved feeling very anxious, engaging in self-damaging behavior such as biting herself, hitting her head against the wall, hitting her head with a telephone, and feeling like screaming. Her sleep had also been quite poor with increasing nightmares and memories of past sexual abuse. At times, she felt as though she was back in the various abusive situations, with a degree of dissociation. She also had a very poor appetite and experienced weight loss.The patient was treated with a combination of Effexor, Trilafon, and Trileptal with some degree of improvement of her anxiety, depression, and irritability. On 4/24/04, she noted, When Im depressed, it doesnt mean I will self-harm and when I feel intense urges to self harm, it doesnt mean Im depressed. Im usually agitated. I can go home for days without depression and forget I even was depressed. Mostly I feel like self-harming afternoon and evenings. The patient was later noted to have some degree of acting out, e.g., lying on the floor in a fetal position for about 30 minutes during which time she was crying. She was amenable to staff and intervention. On 4/25/04, she told her psychiatrist I am learning a lot/growingits not an issue of safety. I am safe. I just want to continue to get the benefits from the program. I do feel more stable. Her psychiatrist felt that based on clinical criteria, continued inpatient treatment was not mandatory. By the point of discharge on 5/6/04 the patient was not actively suicidal.A request has been made for reimbursement for residential treatment services received from 4/26/04 through 5/6/04. The Health Plan has denied the request on the basis that residential treatment was not medically necessary as of 4/26/04.Analysis and Findings:The majority of the patients presentation appears spurred by underlying character pathology, predominately borderline in type. Though medications were also indicated, her psychiatrist felt the patient was sufficiently stable to not warrant any further inpatient treatment as of 4/26/04. Chart notes pertaining to affective display point to a fair degree of vacillation akin to that inherent in her self-abuse. To that extent, accompanied by no further active self-abuse or any true suicidal ideation, a lower level of care as of 4/26/04 would have been medically reasonable and appropriate. Therefore, I have determined that the services at issue were not medically necessary for 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 doxycycline hydrate (Oracea) for treatment of her acne.   The physician reviewer found that acne vulgaris is the most common dermatological disorder in adolescence and young adults. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Doxycycline has been approved by the U.S. Food and Drug Administration (FDA) as adjunctive therapy in severe acne. In adult female acne, the creation of papules, pustules and nodules is mediated through immune mechanisms. Recent observations help understand in greater detail the role that inflammation plays in this disease, and the mechanisms by which doxycycline exerts its effect by modulating inflammatory processes. Berman and Zell concluded that subantimicrobial dose doxycycline is effective in the treatment of acne vulgaris. Oracea is a low dose doxycycline capsule with anti-inflammatory activity in both rosacea and acne vulgaris. As this patient has already failed all other systemic and topical therapies, the requested Oracea 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 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 15 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Three physician reviewers found that according to the American Academy of Pediatrics for the management of children with autistic spectrum disorders, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this case, the request for 15 hours per week of ABA therapy is medically necessary for treatment of the patients autism spectrum disorder. Based on the documentation submitted for review, the patients progress cannot be sustained with the authorized amount of 12 hours of ABA per week. Fifteen hours per week of ABA services are clinically indicated given that his progress has been impacted by the reduction of services. In addition, the best medical practice dictates that if the patient responds best to ABA therapy, then that is what should be implemented. In this case, the patient had been receiving 15 hours per week of ABA services s recommended by his treating therapists and was noted to be progressing as expected. As such, 15 hours per week of ABA was and is medically necessary for treatment of the patients autism spectrum disorder. Final Result: Three reviewers 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in neurology with special competence in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. Additionally, patients with cirrhosis are considered highest priority for treatment.  In treatment-naive genotype 1 patients (cirrhotic or not cirrhotic), therapy is recommended with Harvoni for 12 weeks, as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Based on evidence efficacy in the published literature, and clinical guidelines, Harvoni should be considered medically necessary for 12 weeks in this patients case. Final Result: Three reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old with multiple somatic complaints but no definitive diagnosis. Her primary symptoms include chronic fatigue and hypersomnolence. The patient is on several psychotropic medications including Lexapro, Effexor, and Zoloft. All of these medications could be contributing to the patients fatigue and other symptoms.The case involves a 31-year-old female with a diagnosis of hypersomnolence without narcolepsy or obstructive sleep apnea, and her physician is requesting Provigil 200 mg. The clinical summary of January 2004 from the patients provider indicates the patient has a myriad of medical conditions leaving the patient feeling fatigued and tired with significant nausea, vomiting, abdominal discomfort and somnolence with hypersomnolence. Multiple treatments have been utilized previously; including pain medications and SSRIs. The SSRIs have associated fatigue and hypersomnolence. The medications have not demonstrated any benefit for the patient.The patients medical records do not indicate sleep studies such as polysomnogram and multi-sleep latency test were performed to support the diagnoses of hypersomnolence, narcolepsy, obstructive sleep apnea/hypopnea syndrome, shift work disorder or other sleep disorders. Furthermore, it does not appear the patient has been referred to a sleep study specialist to further investigate the symptoms being experienced. Without such information, Provigil cannot be considered necessary for this patient.Based upon the information set forth above, there is no clinical documentation indicating that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested chiropractic treatment and/or physical therapy services for treatment of her rotator cuff syndrome and cervicalgia. Findings:  The physician reviewer found that this patient suffers from symptoms of right shoulder pain secondary to bicipital tendonitis and rotator cuff impingement which have previously benefited from physical therapy treatment. Non-surgical treatment, based on the imaging results is appropriate for this patients condition at this time. This patient has a need for therapy which increases her shoulder range of motion and decreases her pain. As noted in an article by Camarinos and Marinko, manual physical therapy has been shown to be effective for painful shoulder conditions. Given the patients previous response to physical therapy, she is likely to benefit from a repeat course of therapy at this time. Therefore, the requested physical therapy is medically necessary to treat this patients right shoulder condition. This patient also suffers from cervical pain which was started or aggravated after a motor vehicle accident. The patients chronic cervical pain has responded well to chiropractic therapy in the past, but she still suffers from residual pain. A review of the literature by Gross and colleagues assessed whether chiropractic manipulation and mobilization relieves pain or improves function/disability, improves patient satisfaction, or has a perceived effect in adults with mechanical neck disorders. The authors found that mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. This patient has in fact benefitted from previous chiropractic therapy. Therefore, additional chiropractic therapy, including mobilization and manipulation, is medically necessary to treat this patients cervical pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature. The patient was not a danger to self or others, nor aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that support the level of care provided. The patient was medically and psychiatrically stable. The patients medication management could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patients care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting and could have been provided in an ambulatory level of care. The patient lived with family in a safe, supportive environment. The patient no longer met American Society of Addiction Medicine clinical guidelines for residential level of care. As such, the residential treatment center services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of your medical condition. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year, three-month-old female has requested coverage for a past breast pump rental for treatment of her prematurity.   Findings:  The physician reviewer found that the medical literature supports the superiority of breast milk over formula for the premature infant. Specifically, in a small premature infant, breast milk has been documented to decrease retinopathy of prematurity, accelerate catch-up head growth, and decrease the incidence of necrotizing enterocolitis (De Curtis and Rigo). As the patient ages toward her first year, breast milk decreases allergic responses as well as the incidence of viral infection by the passage of maternal antibodies through the gut. If it can be continued, most providers recommend breast feeding through the first year of life (Hilton). This patients mother has utilized the mechanical breast pump only because the patients ability to suck at the breast is inadequate. In addition, the patients weight at both seven and nine months of age suggested failure to thrive. For these reasons, the mothers milk was a medical necessity. Since the only way for the patient to obtain her mothers milk was by a breast pump, the pump also was a medical necessity through the first year of life.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested radiofrequency endovenous ablation for treatment of her varicose veins.  Findings:  Three physician reviewers found that the records indicate the patient currently has no venous stasis ulcers. With regard to the status of the proposed procedure in the peer reviewed medical literature, currently there is a paucity of evidence to suggest that the planned ablative procedures are better than or as good as standard available treatments. These options may include further evaluation for an occult malignancy or hypercoagulable state in this patient with a significant cancer history and episodes of phlebitis in multiple extremities. In the alternative, extirpation of the offending vein following verification of a patent deep venous system by duplex in the setting of recurrent same area phlebitis or significant symptoms in a manner which would not require ablation of a normal greater saphenous vein. Accordingly, the requested procedure remains investigational and unproven in the clinical publications and is not likely to be more beneficial for treatment of this patients condition than conventional therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Finding: The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Tomosynthesis is becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the presence of breast implants is not, in itself, an indication for tomosynthesis. However, the patient has breasts that have been described as diffusely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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 59-year-old female enrollee has requested for Actiq 400mcg lozenges for treatment of her pain. Findings:  The physician reviewer found that there is a lack of randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are several case series and individual case reports in the literature. Its effectiveness in non-malignant pain remains unproven in randomized controlled trials. Bennett and colleagues described several alternatives to this medication. Per Simon, current limitations to the use of rapid-onset opioids in non-cancer pain include the fact that published studies have focused on patients with cancer-related pain. Simon noted that studies in chronic, non-cancer pain that also measure patient function are needed. Additional unanswered questions include the potential for an increased risk for opioid misuse, potential for rebound pain and the potential for poorer patient compliance when analgesics are dosed as needed versus around-the-clock. Fishman discussed the measurement of pain using a visual analog scale demonstrating the effectiveness of the opiate and the use of an opiate maintenance log agreement along with periodic urine toxicology tests. The documentation provided does not address the use of visual analog scales that demonstrate opiate responsiveness, and there is no documentation of other classes of medications that have been tried. Nor does the submitted documentation include evidence of an opioid maintenance agreement or of any toxicology testing.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni for 24 weeks for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that this patient has cirrhosis proven on CT scan, ultrasound and FibroSURE. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, extended therapy is recommended for patients with cirrhosis who have relapsed after therapy (as is the case with this patient). These guideline recommendations are based on randomized clinical trials, such as the ION-2 trial, which proved the importance of extended therapy in cirrhotic patients with prior treatment failure. Harvoni is FDA-approved for patients with chronic hepatitis C genotype 1. Based on published evidence of safety and efficacy and current clinical guidelines, the requested treatment with Harvoni for 24 weeks is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for radiofrequency ablation procedure for treatment her condition.   Findings:  Two physician reviewers found that There is no recent PET/CT scan available for status of the disease. If a repeat PET/CT confirmed that there are no other metastases, radiofrequency ablation would be likely to be of benefit. However, if there is evidence of other metastases, then it would not be likely to be of benefit. Absent this information, the medical indication for the requested procedure cannot be established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested orthodontic care for treatment of the enrollees arch length discrepancy. The physician reviewer found that to qualify for orthodontic treatment, the patient must meet specific criteria on an objective scale which assesses the relative disability. In this case, the handicapping labiolingual (HLD) index was utilized. There is no clinical indication that any of the specified criteria are met due to severe handicapping situations or compromise of health. The computed score on the HLD index was 11, which is well below the accepted minimum score of 25 required to indicate a severe handicapping malocclusion. Therefore, based on the patients records and with minimal crowding of the teeth, the requested orthodontic treatment is not dentally necessary.  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 oral and maxillofacial 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.