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

A 52-year-old male enrollee has requested intravenous immune globulin (IVIG) for treatment of his chronic inflammatory demyelinating polyneuropathy (CIDP).   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested IVIG therapy. This patient has had progressive numbness and burning pain in the feet, and has been shown to have a mixed sensory-motor demyelinative and axonal polyneuropathy. He has been diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), and has had treatment with IVIG, which has not resulted in observed improvements. The preferred therapies for CIDP include IVIG, steroids, and plasmapheresis. An evidence-based guideline from the American Academy of Neurology (AAN) states that, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). Although this patient has been treated with IVIG without observed improvement, a longer trial is indicated to determine whether he will respond to the treatment.  Therefore, it is medically necessary to continue IVIG treatment for a span of an additional year to help define if the patient has actually responded, and to further clarify the diagnosis. While the patient has requested lifetime authorization of IVIG, neither the patients clinical findings nor the scientific literature support the lifetime use of IVIG. Thus, continued IVIG treatment for a one-year period is medically necessary and appropriate for this patient. The patient should be re-evaluated at the end of the one-year period to determine the appropriateness of further treatment with IVIG therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel. The records reviewed document that this patient has a history of nephrotic syndrome (NS) secondary to membranous nephropathy. The patients NS has been refractory to treatment with the Ponticelli protocol and rituximab. The patients provider has recommended treatment with Acthar Gel. As noted in the medical literature, Acthar Gel is not supported for treatment of patients as first-line therapy. However, there are adequate data supporting the use of Acthar Gel in the treatment of patients who have failed to respond to first- and second-line agents, as in this patients case. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. Based on this patients failure to respond to treatment with the Ponticelli protocol and rituximab, Acthar Gel is indicated for this patients refractory disease. Therefore, the requested Acthar Gel is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy syringe. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Although Plegridy has been shown to reduce disease activity in relapsing-remitting multiple sclerosis, the current medical evidence has not demonstrated that this medication is more efficacious than other approved therapies. In this patients case, the Health Plan has offered Copaxone, Extavia and Gilenya as alternatives. These alternatives are medically appropriate. The records document previous treatment with Betaseron. However, there is no documentation of failure of the formulary alternatives. All told, the medical necessity of Plegridy syringe has not been established.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 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: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a power scooter for treatment of her functional quadriplegia.  Findings:  The physician reviewer found that wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario (Dicianno and Tovey; Johnson and Fitzsimmons). In the current case, the patient was assessed by a physical therapist in the community with respect to her mobility issues. There were no significant neurological deficits or impairments in upper or lower limb strength, coordination, or range of motion. There were no impairments that would preclude the use of an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion for accomplishing her mobility-related activities of daily living. In addition, the patient has multiple chronic health conditions, such as obesity and chronic pains that would benefit from increased physical activity and exercise (Hagen, et al; Samson and Garber). Regular use of a power mobility device would decrease her physical activity levels and exercise and would be expected to worsen her chronic health conditions in the long-term. A power mobility device is not medically necessary for this patient given that her mobility deficits can be addressed by other means, which are expected to be more beneficial than a power mobility device.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested once weekly acupuncture for treatment of his neck and back pain.  Findings:  The acupuncture reviewer found that the submitted information did not include clinical records documenting the patients prior course of acupuncture. Thus, there was no objective evidence that the patient previously responded to acupuncture.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging for treatment of the enrollees knee pain.Findings:  The physician reviewer found that the American College of Radiology (ACR) has established appropriateness criteria for the evaluation of various clinical presentations. Under their category of chronic atraumatic knee pain, the first recommended study is a plain x-ray, which this patient has already had.  In patients with demonstrated degenerative changes, in consideration for surgery, the ACR considers MRI appropriate.  As stated by the ACR, MRI is more sensitive than radiography and provides more specific information compared with radionuclide bone scan.  MRI of non-traumatic knee pain may document a joint effusion, communicating popliteal cysts, proliferative changes of the synovial membrane (such as, but not limited to lipoma arborescens, synovial chondromatosis, or synovitis associated with arthritis), osteophytes, subchondral cysts, articular cartilage loss, meniscal and/or ligamentous tears and/or degeneration, extensor mechanism disorders, bone marrow edema (bearing in mind that actual edema is not a major constituent of this abnormal edema-like signal in the setting of osteoarthritis), fractures, and osteonecrosis. In this particular patient, there is evidence of degenerative disease.  As noted by the patients primary care provider, there are multiple treatment options.  While one should never rush into surgery for the knee, as acute symptoms will often resolve, an MRI can be used to evaluate this patient prior to making treatment decisions. The Health Plan has suggested that the patient should first see an orthopedist. However, in this patient, with radiographic signs, a standard practice by most orthopedist will request an MRI often before seeing the patient. In conclusion, MRI of the knee is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 two-year-old male enrollee has requested  coverage for speech therapy for treatment of the enrollees expressive and receptive language delays. Findings:  The physician reviewer found that speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested for the Vest Airway Clearance System for treatment of his restrictive and obstructive lung disease. Findings:  The physician reviewer found that daily airway clearance is essential to maintain pulmonary hygiene. The enrollee has had multiple exacerbations of pneumonia and bronchitis requiring antibiotics.  On occasion, he has required acute hospitalization. Standard chest physiotherapy is not feasible since the enrollee does not have assistance, hence failure of standard treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria will be utilized. This is an accepted, national standard for determining the appropriate level of care for adults. The records supported a score of 2 with regards to risk of harm. No documentation could be found of a history of suicide attempts. In terms of functional status, the records support a score of 3.  Her schizoaffective disorder appears to have significant impairment on the patients life. Recent gains in functionality have been achieved while participating in structured and protected settings. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has a significant comorbidity of schizoaffective disorder, bipolar type and anxiety. However, she was medically stable and did not require 24-hour monitoring for any medical conditions. With regards to recovery environment, the records support a score of 3. The patients mental health condition has led to a moderate stressful environment. In terms of level of support, the records support a score of 3. It appears that the patient has a few supportive resources which may be capable of providing some help if needed.  With regards to treatment history, the records support a score of 3. The patient has had a moderate response to treatment and recovery. The patient had a calm affect, and she was compliant with medications. She was eating well. She did not have any suicidal or homicidal ideation. She did not have any auditory or visual hallucinations. She did not have any paranoia or mania. She continued to have anxiety.  In terms of engagement and recovery status, the records support a score of 2. The patient had a positive attitude toward recovery. She had positive relationships with staff. She was compliant with treatment recommendations. Thus, the records support a total score of 19. Based on these criteria, the patient would meet criteria for an intensive outpatient program. The patients medication management could have been accomplished in an outpatient setting. 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: Overturned

The parent of a two-year-old female enrollee has requested a speech and language assessment and speech therapy services for the evaluation and treatment of the enrollees suspected language delay.  Findings:  The physician reviewer found that this patient has an identified speech delay in receptive and expressive language of approximately 50% per the Rossetti Infant-Toddler Scale and Hawaii Early Language Profile. Speech therapy is indicated with any delay greater than 25%. An extensive review of the literature, including a meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately 50% of children delayed at 2 years catch up to peers by 3 years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children involved in early intervention services with parental interaction and teaching show stronger language skills than children who do not receive early intervention. Children who participate in speech-language treatment show better improvement than those children who have no treatment. This patient has been involved in early intervention services without improvement in language delay. Speech therapy is medically necessary for this significant delay, at greater than 50%, of expressive and receptive language.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper eyelid blepharoplasty. The criteria for upper blepharoplasty are not met in this case. The patients visual field deficit does not extend to within 30 degrees of fixation. In addition, there is no documentation of more than 30 degrees of improvement in the visual field with the eyelids taped up compared to primary gaze. Furthermore, the photographs show an upper eyelid margin pupillary light reflex distance (MRD-1) of about 4-4.5 mm. This indicates a completely unobstructed visual axis. Although the patients condition constitutes an abnormal structure of the body, the requested surgery will not improve function based on the eyelid taping results, and will not provide a more than minimal improvement in the patients appearance. Thus, the requested upper eyelid blepharoplasty is not medically necessary and not reconstructive in nature. 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 ophthalmology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees dyslipidemia. Findings:  The physician reviewer found that this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including apolipoprotein B, lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board 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: Overturned

Nature of Statutory Criteria/Case Summary: There is sufficient support for the services at issue in this clinical setting. The provided documentation indicates that, the patient remained symptomatic. The psychiatrist noted that the patient was depressed and irritable, cursing and negative towards staff and peers, not adequately attending to activities of daily living, stealing food and overeating. Due to the patients persistence of symptoms, her dose was increased to further target these symptoms. The patient was noted to be isolative and demonstrate oppositional behaviors similar to those that occurred prior to her admission.  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 for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths 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 as outlined above, the patient met CASII criteria for 24 hour psychiatric monitoring. The patients clinical status and current medical literature support the patients treatment at the residential level of care. Therefore, residential treatment center services were medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Fulfills requirement of 1374.33(h)(1)(I)