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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Humira 20 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients plaque psoriasis. The submitted documentation supports the medical necessity of the requested medication. skin disease, which typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients who are moderately or severely affected by the disease. Approximately 20 percent of patients have severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30 percent of psoriatic patients develop psoriatic arthritis (also known as psoriatic arthropathy), a type of inflammatory arthritis. Humira (adalimumab) is a fully human tumor necrosis factor-alpha monoclonal antibody approved for the treatment of rheumatoid arthritis, which is also used in treating other conditions, including psoriasis and psoriatic arthritis. Open prospective studies and randomized controlled trials have shown the short-term efficacy of adalimumab in psoriatic arthritis and psoriasis. There is sufficient support for the requested medication in this clinical setting. Humira has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe chronic plaque psoriasis. The approval was based on the results of two trials that showed marked improvement in skin condition. Therefore, Humira 20 mg is medically necessary 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 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 patients parent has requested authorization and coverage for weekly psychotherapy sessions. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presents with some risk of harm (score 2) due to recent suicidal ideation. The patient has mild functional issues (score 2) with deterioration in his expected level of functioning and inability to regularly attend school. The patient has no reported co-morbidity (score 1) such as active serious medical problems or substance use. The patients recovery environment is minimally stressful (score 1) and his recovery environment is supportive (score 1) as his family is actively involved in treatment. The patient has demonstrated limited response to previous treatment (score 3) with continued symptoms. The patient has been constructive in treatment (score 2) and his parents work actively with providers (score 2). This gives the patients presentation a composite score of 14, which correlates with outpatient services. Given this support, the requested weekly psychotherapy sessions are medically necessary for treatment of this patients behavioral health issues.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 psychiatry with subspecialty 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

A 23-year-old male has requested the Novolog Flexpen Syringe/Lantus (prefilled insulin syringe/cartridge) for treatment of type I diabetes mellitus.  Findings:  The physician reviewer found that this prefilled insulin syringe/cartridge is clearly a convenience item in this instance. There is no indication the patient has a disability or physical impairment that would prevent him from learning to accurately draw his insulin dosage from a multi-dose vial or to securely store the medication and syringes.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 150.5 hours per month of applied behavioral analysis (ABA) therapy necessary for treatment of the enrollees autism spectrum disorder. Findings: The physician reviewer found that the Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient has made progress with ABA therapy, but he continues to demonstrate dangerous behaviors of aggression and elopement. Given the medical necessity of ABA therapy for children with autism, coupled with the patients maladaptive behaviors that include elopement, aggression and stereotyped/repetitive behaviors, the request for 150.5 hours per month of ABA is medically necessary for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 64-year-old female with a 16-year history of peripheral neuropathic pain who has failed treatment with multiple medications including tricyclic antidepressants, SSRIs, Neurontin, Cymbalta, Tegretol, Trazadone and Effexor. She has required significant amounts of narcotics for pain control. The patient was provided with samples of Lyrica and this medication has afforded excellent symptom relief and her quality of life has improved. The patients request for reimbursement and prospective authorization of Lyrica was denied by the Health Plan based upon a determination that the medication was/is not medically necessary.The patients peripheral neuropathy is severe and unquestionably refractory to standard treatments as numerous pharmacological agents have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies, and historically medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown an excellent response to Lyrica and continued treatment is medically indicated. Based upon the information set forth above, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. In this case, the medical needs of the enrollee do not support that the services in issue were medically necessary. On admission, the patient indicated that she was not suicidal, and she gave a reason for not being suicidal. The patients mood rapidly improved after changes in medication. As of the date that the services in issue commenced, the patient appeared to be stable and to be able to cooperate and participate in therapy. The submitted documentation reflects that the patient could be treated at a less restrictive level such as a partial hospitalization program or an intensive outpatient program. While there is mention that the patient had a complex combination of medications that required medical observation, there is no indication of frequent psychiatric evaluation. Accordingly, Residential Treatment Center services were not medically necessary to treat the enrollees medical condition during the period in issue.Final Result: The reviewer determined that the services in 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 patient is a 37-year-old female who was non-weight bearing after a motorcycle accident in June 2006. She received rehabilitation therapy which included sliding board transfers and activity of daily living (ADL) training. The patient progressed steadily with physical therapy (PT) from initially requiring maximum assistance in bed mobility and transfers to stand-by assistance/supervision in bed mobility and transfers and independence in wheelchair propulsion. As of July 2006 the patient required minimal to moderate assistance in toileting. In July 2006, after OT and PT were curtailed, the patient required maximal assistance for sliding board transfers. The patient has requested authorization for skilled nursing facility services provided after July 2006. The Health Plan denied her request based upon a determination that the requested services are not medically necessary.The patient was not ready for discharge in July 2006 as she was not independent in her PT and OT modalities and was continuing to make progress. Rehabilitation services continued to be medically appropriate. Additionally, the patients functional abilities regressed when her therapies were reduced and/or discontinued. The record indicates the patient attained weight bearing status in July 2006. SNF services should continue for one additional week and then the patients need for continued services should be reassessed.Based on the information cited above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90 mg/400 mg for 12 weeks. Findings:  The physician reviewer found that according to the 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 limited life expectancy due to non-liver-related conditions. According to the guidelines, patients with cirrhosis are considered highest priority for treatment. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks, but not Harvoni alone for 12 weeks. This recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population. Zepatier is not one of the several AASLD/IDSA recommended regimens for treatment of genotype 1a hepatitis C in patients with decompensated cirrhosis or severe hepatic impairment. Studies of Zepatier have not included patients with this level of liver disease . For these reasons, although treatment is needed in this case, the requested treatment with Harvoni monotherapy for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewers 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: Physician reviewer number one 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 an integrative medicine consultation.In this case, the patient reports chronic non-cancer pain that started after a motor vehicle accident several years ago. This accident caused the patient to experience traumatic injury to the head and neck region with fractures to the sternum, and while her recovery was uneventful, the accident has affected the patient in ways that continue to manifest in her current symptomology. Records reflect that the patient has had medical evaluation and treatment for any physical ailments including cardiac and gastrointestinal etiologies. The patient did have an incidental finding of a large benign hepatic cyst which was successfully removed surgically. Even with these essentially negative findings, the patient has continued to complain of frustration with persistent abdominal pains, constipation, dry mouth, hyperalgesia and sleep disturbance, and records suggest that she does also exhibit some amount of depression. The submitted records do not reflect that the patient has received treatment in a chronic pain clinic with multispecialty support or that she has received treatment centered around cognitive behavioral therapy, counseling, physical therapy or treatment for possible depression. While the patient currently seeks an integrative medicine consultation, there is no indication that this service would be provided in conjunction with appropriate management by a medical team specialized in chronic pain treatment. Under these circumstances, the requested integrative medicine consultation is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 two-year-eleven-month-old male enrollee has requested for speech therapy, occupational therapy and physical therapy for treatment of the enrollees multiple medical conditions. Findings:  The physician reviewer found that children with speech delay can be readily treated (Law, et al.) and children with severe cognitive delays can be candidates for successful speech therapy (Goorhuis and Brower).  In regards to occupational and physical therapy, Carboni, et al. states that muscle stretching by physical therapists is essential for patients in this situation to develop improved motor function. Schaaf and Miller report that sensory integration by occupational therapists for children with multiple combinations of developmental sensory and motor delays has been effective. Although the study by Roberts is a single case study, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing sensory motor techniques.Given the patients medical conditions and the medical consensus found in the peer reviewed medical literature, it is medically necessary that this patient receive physical therapy, occupational therapy and speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trikafta. The U.S. Food and Drug Administration (FDA) approves the use of Trikafta for the treatment of cystic fibrosis in patients who have at least one F508del mutation in the CFTR gene. Heijerman and colleagues report that in a four-week treatment period, triple therapy with elexacaftor, tezacaftor, and ivacaftor provided clinically robust benefit in FEV1 and in symptom-related quality-of-life compared with double therapy with tezacaftor and ivacaftor alone, with a favorable safety profile. Given that current medical literature supports the efficacy of Trikafta in this clinical setting, the requested medication is medically indicated. Therefore, Trikafta is medically necessary 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 pulmonary diseases 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 13-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that growth hormone (GH) therapy for treatment of the diagnosis of idiopathic short stature (also called nongrowth hormone deficient short stature) was approved by the Food and Drug Administration in 2003. According to the FDA approval, GH is indicated in patients who meet the following criteria: have a height at least 2.25 standard deviations below the mean for age; have growth rates unlikely to permit attainment of adult height in the normal range; epiphyses are not closed; and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. In this patients clinical situation, the submitted documentation demonstrates that the patient meets the FDA criteria for GH therapy.The use of GH in non-GH deficient states associated with short stature (such as Turner syndrome, Prader-Willi syndrome, Noonan syndrome, chronic renal insufficiency and children born small for gestational age) is widely considered to be appropriate and restorative in nature within the endocrinology community. All indications for GH therapy intended to increase the final adult height are, in a sense, restorative in nature regardless of whether there is a documented GH deficiency.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for breast reduction mammoplasty for treatment of her back, neck and shoulder pain. Findings:  The physician reviewer found that the patient with evidence of possible symptomatic macromastia.  She has chronic neck and back pain that affects her posture negatively and activities of daily living.  She has undergone conservative management of her pain with physical therapy, stretching and medical management. She has suggestion of possible symptomatic macromastia. However, the planned amount of resection was not provided for this patient. The American Society of Plastic Surgeon has guidelines for the requested procedure. One of the guidelines recommend that Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by a breast specific questionnaire which includes at least two of the following signs/symptoms: Chronic breast pain due to weight of the breasts; Intertrigo unresponsive to medical management; Upper back, neck, and shoulder pain Backache, unspecified; Thoracic kyphosis, acquired; Shoulder grooving from bra straps; Upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area  Headache; Congenital breast deformity. Hammond and Loffredo note the following, Also, the presence of common symptoms related to strain on the upper torso attributable to the weight of the breasts must be documented. These symptoms can include headaches, neck pain, back pain, submammary intertrigo (particularly during the warmer months), painful bra strap marks with grooving and possible associated ulnar paresthesias caused by pressure on the brachial plexus, breast pain, difficulty wearing clothing that fits proportionately, and emotional sequelae (particularly in younger girls). In this patients case, the submitted documentation does not meet the above criteria. A radiograph report of the cervical spine did not note an etiologic finding. While the photographs do confirm macromastia, the records did not provide the planned resection for each breast. For this patient, the diagnosis of macromastia was not adequately defined and supported by examination detail. For these reasons, breast reduction mammoplasty is not medically necessary for treatment of this patients medical condition based on the documentation provided.Final Result: The reviewer determined that the requested procedure 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 plastic 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.