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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  All told, Harvoni is medically indicated for the 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 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

The patient is a 54-year old woman with significant risk factors for coronary artery disease (CAD) including family history, marked elevation of LDL and systemic hypertension.  There was a trial of Lipitor with no clear elevation of her CPK or proximal muscle weakness.  The patient is requesting authorization and coverage for Zetia, and the Health Plan has denied her request based upon their determination that Zetia is not medically necessary. The current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines strongly favor the lowering of LDL in a patient such as this with three risk factors and an elevated LDL. The data best supports a statin in terms of efficacy and safety.  There is specific data that favors an ace-inhibitor and Lipitor as having a direct impact on mortality.  There are indeed patients that cannot tolerate statins due to CPK-negative myalgia/ weakness syndrome.  However, the trials that support that the use of Zetia are efficacy only (reduction of LDL) and do not include safety or mortality benefit data.   A large amount of safety/mortality data does exist for the statin drugs, and therefore the current standard of practice is to try another statin, such as lovastatin, Pravachol or Zocor and see if the myalgias still occur.  If trials of formulary alternatives (another statin or niacin) are unsuccessful, then alternative medication such as Zetia would be tried with an understanding that data regarding the safety and mortality benefit is still lacking.  Many patients are able to tolerate a second or third statin, especially if the potency is lowered.  The Health Plan requirement that an alternative statin drug be tried first is a reasonable one, and is consistent with current medical practice guidelines.  Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 35-year-old male enrollee has requested for emergency services for treatment of his buttock abscess.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a large buttock abscess with 10/10 pain would reasonably expect the absence of emergency care to jeopardize their health. The patients pain level and the fact that the abscess required operative excisional debridement support the need for immediate care. Infected dermatological abscesses are normally incised and drained in the ED under local anesthesia and only go to the operating room if complex.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment services for the treatment of the enrollees substance abuse and major depression. Findings:  The physician reviewer found that there is insufficient evidence to support the contention that the patient required residential treatment of his polysubstance abuse and behavioral disorder. The patient met criteria for outpatient/intensive outpatient rehabilitation at the time of his evaluation at an outpatient treatment facility, as documented in his evaluation. He was participating in treatment. The notes document that he was confronting issues regarding his willingness to stay drug free and sober.  According to subsequent notes, the outpatient facility was notified by the patients mother that the patient was readmitted to an inpatient treatment facility. There is no documentation of a recommendation from the outpatient facility that the patient be admitted to an inpatient facility, nor any documentation to suggest that the outpatient facility was recommending a higher level of care at that point. It is not unusual for patients to have some episodes of drug/alcohol use during the rehabilitation process, and it is not indicative that the patient will ultimately have a poor treatment outcome. Further, these episodes provide an opportunity for analysis during therapy of the triggers that led to relapse. The notes subsequent to that incident indicate that the patient was developing some insight into the triggers of this behavior. The readmission note to the inpatient facility states that the patient was attending a seminar and walked out of it, so his parents decided to have him readmitted. This does not constitute medical necessity for the readmission.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested post-acute inpatient cognitive rehabilitation for treatment of his status post traumatic brain injury.  Findings:  The physician reviewer found that the records indicate that the patient sustained multiple major injuries due to a motor vehicle accident, including traumatic brain injury and fractures of the face, axial skeleton and ribs. He has undergone acute inpatient rehabilitation and has made significant functional progress since the accident. He is off of respiratory support. The patient is stable on an oral diet. He is independent with his mobility. He is independent to supervision for his activities of daily living. He has been discharged to the community with family.Despite this progress, the patient continues to have residual cognitive deficits. He does require some ongoing rehabilitation services going forward.  The records, however, do not support the need for post-acute inpatient cognitive rehabilitation services at this time.  Currently, the research in the field of cognitive rehabilitation after acquired brain dysfunction does not permit firm conclusions regarding efficacy.  Methodologically weak literature, such as observational papers without control groups, have suggested some benefits to various cognitive therapy interventions, but have failed to discern treatment effect from natural improvements due to continued healing. In the sparse literature that has utilized relatively rigorous methodology, cognitive therapy interventions have not been demonstrated to have a significant, sustained effect on long-term functional outcomes over basic education, home cognitive exercises, reassurance, and the passage of time, as noted by Cicerone and colleagues. Overall, there are no realistic goals for the proposed readmission to acute inpatient rehabilitation stay that could not alternatively be met with rehabilitation services provided at a less intense setting, such as outpatient rehabilitation. All told, the requested post-acute inpatient cognitive rehabilitation is not in accordance with nationally recognized standards of medical practice given that further care could be provided at a lesser intensity level of care. Thus, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary angiography. The Health Plan has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees abnormal chest pain.Based on the records provided the patient has documented coronary disease, but the presenting symptoms do not have features concerning for coronary ischemia. In this circumstance, if further evaluation is indicated, then some form of repeat stress testing would be appropriate. In this case, CT coronary angiography is not medically necessary since it does not assess the functional significance of any stenosis identified and a link has not yet been established between the patients symptoms and coronary ischemia. Moreover, if an assessment of coronary anatomy is indicated, then conventional coronary angiography would be preferred due to improved accuracy of the test relative to coronary CT angiography and the ability to intervene with coronary revascularization during the same procedure. All told, the requested CT coronary angiography is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is 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 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: Experimental/Investigational
Decision: Upheld

A sixty-three year-old female with degenerative lumbar disc disease is requesting reimbursement for an electrical bone growth stimulator.  The patient underwent a number of spinal surgeries for fusion and decompression.Reviewers Findings:The three reviewing physicians found that a bone growth stimulator is indicated only for a high-risk fusion patient. With regard to this patient, the record makes no reference to risk factors other than hypertension and she underwent a single-level fusion.  Also, the clinical record does not suggest that the patient would realize any additional benefit with the use of the bone growth stimulator.  Therefore, the three reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male who has recently undergone resection of a T2N3 high-grade mucoepidermoid carcinoma of the tongue base. The procedure was performed by an out-of-plan provider. The patient was initially diagnosed by a biopsy performed in February 2005. A CT scan was also performed and the patient was referred for consultation to an in-plan radiation oncologist, medical oncologist and to a head and neck/microvascular surgeon. The patient consulted with an out-of-plan provider in February 2005 and was more comfortable with the information the out-of-plan surgeon provided regarding the planned procedure. Therefore, the patient chose to have the surgery performed by the out-of-plan provider. The patient was offered an additional in-plan consultation in March 2005, but declined this and underwent transhyoid approach to tongue base resection as well as right modified neck dissection in March 2005. Based upon the information provided, it appears the patient has not yet returned for follow-up with post-operative radiation therapy, which was scheduled to begin in April 2005. At issue is whether the surgical services performed by the out-of-plan provider in March 2005 were medically necessary for treatment of the patients condition.The patient decided to pursue surgery with an out-of-plan provider evidently because he was more agreeable to the surgery proposed by the out-of-plan provider than with the procedure discussed with him by the in-plan providers. Review of the submitted evidence does not demonstrate the procedure proposed by the in-plan providers was different than the procedure that was proposed by the out-of-plan provider. Nor, is there evidence the in-plan providers were incapable of performing the same surgery that was performed by the out-of-plan provider. While laryngectomy is generally avoided unless laryngeal structures are involved with the tumor margin, a decision regarding laryngectomy is often made at the time of surgery based on the extent of the tumor. If tumor margins extend further than expected, either partial or total laryngectomy may have to be performed for complete oncologic resection. In addition, reconstructive methods may include primary closure or the use of pedicled or free tissue transfer, again depending upon the extent of resection and surgical technique. The patient needed to be made aware of these possibilities preoperatively.Based upon the evidence provided, the surgical services received from the out-of-plan provider were available from the in-plan providers. As such, 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: Upheld

A 65-year-old male enrollee has requested substance abuse treatment services for treatment of his polysubstance abuse. Findings:  The physician reviewer found that although this patient had a long history of alcohol dependence, his benzodiazepine use was negligible. The patients CIWA score was predominantly weighted from the anxiety domain, which is a subjective rating. In terms of objective signs and symptoms of alcohol withdrawal, there were virtually none. This suggests the CIWA score on admission was more accurately on the range of 6. This data in combination with vitals, even after hydration, indicates that this was not an inpatient detoxification. This patient had a supportive family, reported no suicidal or homicidal ideation, was motivated for treatment, and had no serious comorbid medical conditions. Applying the American Society of Addiction Medicine (ASAM) guidelines, the patient could have safely been detoxified on an outpatient basis over a period of 2-3 days. After detoxification, the patient could have been enrolled in an intensive outpatient program (IOP). Consistent with these findings, the services at issue were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Oxycodone-Acetaminophen and Tramadol for treatment of the enrollees cervicalgia, radiculopathy and sciatica. Findings:  The physician reviewer found that based on the documentation submitted for review, Oxycodone-Acetaminophen and Tramadol have not been established as medically necessary for treatment of the patients medical condition. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. In addition, short-acting opiates are likely to cause adverse outcomes. Therefore, based on current medical literature and in consideration of the presented clinical records, Oxycodone-Acetaminophen and Tramadol are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male has requested long-term acute care for treatment of multiple medical problems.  Findings:  The physician reviewer found that the patient does not have hospital level of care needs. He does not need advanced monitoring, advanced whirlpool, daily physician rounds, or therapy that is not routinely provided in a SNF. His wound care is a daily dressing change. This type of care is also provided at home and does not warrant an acute level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections (CPT J7324) to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient did not respond to NSAIDs, corticosteroid injections, physical therapy, and ice. The presence of crepitus and negative McMurrays sign as well as absence of a history of trauma supports the presence of a degenerative process causing severe pain. In light of the patients presentation and age, he is a good candidate for treatment with viscosupplementation. Therefore, the requested Orthovisc injections (CPT J7324) to the right knee are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic 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.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested residential treatment center (RTC) services and partial hospitalization program (PHP) services for medical treatment of her anorexia nervosa and anxiety.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the patient meets admission and continued stay criteria for a PHP level of care. However, the records do not support the medical necessity of RTC level of care services. In this case, the patient appears to have motivation for treatment as judged by her cooperation and openness in treatment. Due to her failure of outpatient treatment, it appears that more structured treatment is warranted in order to stop her rapid weight loss. She has no documented episodes of orthostasis and her bradycardia is also not problematic. In addition, the patients problems with purging behaviors, over exercising, and anxiety support the continued need for treatment at the PHP level of care. All told, RTC services were not medically necessary, while PHP services  were and are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has been diagnosed with anorexia nervosa, MDD, panic disorder with agoraphobia and alcohol abuse in remission was admitted to the residential treatment facility for treatment of her eating disorder. Upon admission, this patients vital signs were normal and her weight showed her BMI to be 17.5. This patients physical examination was also normal. She was not showing any signs of physical compromise and did not reportedly demonstrate any psychiatric symptoms other than the eating disorder and occasional anxiety related to discharge. Applying the American Psychiatric Association (APA) treatment guidelines for patients with eating disorders this patient does not require 24-hour medical and nursing supervision for her condition as provided at the residential treatment facility level of care and is a candidate for treatment at a lower level of care such as an outpatient program. All told, this patient does not meet the medical necessity criteria for admission and treatment in a residential treatment facility for mental health issues including her eating disorder as of the said date and forward.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found the submitted documentation does not support the medical necessity of the residential treatment services. Upon admittance to the residential treatment facility, the patient was coherent in thought, cooperative in behavior and normal in intellect. He was not suicidal, homicidal, manic or psychotic. He was enduring neither an acute psychiatric syndrome nor an emergent medical crisis during his admission. There was no mention in the initial assessment that the patient had failed comprehensive services in a less restrictive setting during that particular episode of illness. Based upon the medical records provided, there is a lack of evidence that the residential treatment setting was improving the patients condition or was necessary to prevent a more serious illness during this admission. Therefore, residential treatment services were not medically necessary.