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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for residential treatment services provided. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  In this particular case, the patients addictive illness was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. She reported an early age of first use for multiple substances that steadily progressed and jeopardized her well-being. Her motivation was undermined by poor self-worth, dependent personality traits and a dysfunctional marriage with a spouse who reportedly was actively using substances in the home.  The patient also had co-occurring depression, chronic suicidality, anxiety and trigeminal neuralgia, conditions that were more than likely negatively impacted by her substance use.  Finally, despite efforts to quit on her own and attendance at community meetings, the patient was unable to achieve meaningful sobriety in her environment.Per the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting by date of dispute was likely to have relapsed in a community-based setting if discharged that day.  Although she opened up in group to an extent that had yet to be seen during the admission, she was described by the therapist that day as anxious, hypervigilant, tearful and depressed. The patient feared her addictive tendencies and broached her underlying poor self-esteem.  Further, she had not yet found a sponsor.  On date of dispute , she was labile. Moreover, she had not completed family week, which was a particularly critical element of care critical in this case. Thereafter, the records indicate that the patient was actively engaged in treatment until the day of discharge, which included completing a contentious family week, securing a sponsor and developing an aftercare program consisting of an alternative residence and intensive outpatient programming. The services and setting were safe, appropriate and consistent with good practice in the United States, while the duration of treatment aligned with community standards and ultimately facilitated a transition of service delivery to a less restrictive setting. All told, residential treatment services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg oral tablets for 12 weeks. Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies regardless of fibrosis score. The guidelines recommend that treatment-naive genotype 1b patients should be treated with Zepatier for 12 weeks, regardless of NS5A resistance testing results. These guideline recommendations are based on high-quality clinical trial data. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 parents of a 16-year-old female enrollee have requested for inpatient psychiatric treatment for treatment of her bipolar and major depressive disorders. Findings:  The physician reviewer found that the patient may suffer from a Unipolar or a Bipolar Disorder, she does not appear to have had any concerted treatment on an outpatient basis at all. Outpatient treatment in the form of either intensive outpatient therapy or partial hospitalization was more appropriate for this patient and could well address the dynamics and result in some improvement. All told, the patient was not and is not so affectively stricken as to preclude outpatient treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was engaged and participated in treatment. Although the patient initially reported thoughts of self-harm, the records do not document thoughts of suicide or self-harm during the dates of service in dispute. The patient was cooperative and did not have aggressive behaviors toward staff or peers. The documentation indicated that the patient was making progress with his understanding of his anxiety. There was no documentation that the patient was not attending to his activities of daily living. The patients family is supportive of the patient. Based on the records, he did not have medical problems which required 24-hour supervision. There was no documentation that the patient was using illicit substances. The patient continued to have anxiety, but this treatment could have taken place in a less restrictive environment. It is standard of care to treat the patient in the least restrictive environment possible. Per the medical records, the patient had improved enough to be discharged to a less restrictive environment. Thus, residential treatment provided was not medically necessary for the treatment of this patient. 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 with expertise 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the psychiatric residential treatment services rendered. Findings:  The physician reviewer found that Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains. However, episodic placement in more restrictive settings is often clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. In this patients case, the patient reported co-occurring depression and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders are difficult to treat and generally have poorer outcomes. Additionally, the early age of onset, and subsequent chronicity of symptoms, were additional factors suggestive of a formidable illness burden and the need for a conservative course of treatment. Further, during the episode of illness, the patient had previously failed treatment in a less restrictive setting. Thus, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve the patient's  condition and prevent a more serious episode of illness. Considering the clinical presentation and current peer-reviewed literature, the psychiatric residential treatment services rendered were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 61-year-old female enrollee has requested skilled rehabilitation for the treatment of her medical condition. Findings:  The physician reviewer found that the medical records demonstrates that while in the skilled nursing facility the patient was alert and oriented, continent, had a foley catheter, medically stable, and did not require parenteral medications or skin care. She was receiving bladder training and daily physical therapy. Initially she was non-ambulatory due to her non-weight bearing status, but was eventually cleared for toe-touch weight bearing status and was able to ambulate with a front-wheeled-walker with moderate assistance. Her transfer status was stand-by-assistance. Her ambulatory status eventually progressed to contact-guard assistance and her bed mobility increased to an independent level. However, her weight bearing status was changed back to non-weight bearing due to concern about the healing of her fracture. The patient received occupational therapy and she gained steady progress in that area with most of her difficulty being in donning her socks. All told, this patient required skilled rehabilitation and was making progress with her mobility training, activities of daily living training, and bladder training throughout this period. However, due to her weight-bearing status being changed back to non-weight bearing, further significant progress was not expected with her activities of daily living or her mobility training. In addition, her bladder training had ceased. In summary, the patient had achieved her maximum potential with her activities of daily living and mobility given her new weight-bearing status with further significant progress not being expected.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 20-year-old female with a history of protein C deficiency who presently has extensive deep vein thrombophlebitis extending through all the veins of the lower extremities, pelvis and inferior vena cava. She has an inferior vena cava filter, which was placed on 2/17/05. She has failed a variety of conventional treatments for deep vein thrombosis including Lovenox, Heparin, tissue plasminogen activator and Coumadin. She was admitted on 3/5/05 for evaluation of abdominal pain. A CT scan demonstrated inferior vena cava thrombosis with thrombus extending into the renal vein unilaterally with some perinephric edema. She was evaluated by hematology and placed on Refludan. She has received IV Refludan therapy, but will require therapy with this agent for a period of 12 months. She has been recommended to receive the Refludan via subcuticular injections administered twice daily.The documentation provided indicates the patient has responded to Refludan therapy. She has evidence of Heparin induced thrombocytopenia (positive antibody test) in addition to protein C deficiency and Refludan is the treatment of choice. She will require therapy for a period of 12 months. The literature has demonstrated the ability of the Refludan to be administered via the subcuticular route providing the desired prolongation of the partial thromboplastin time necessary for effective therapy for a period of 12 months. Continuing treatment via IV infusion would not be a feasible option for self-management. Refludan therapy is medically indicated for treatment of the patients thrombotic condition and should be administered in a manageable and effective way. Therefore, I have determined that subcuticular administration of Refludan is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient drug and alcohol treatment. The submitted documentation supports the medical necessity of the requested services. In this case, the patients medical condition was complicated by bipolar illness, which is a severe mental disease that has poor outcomes and an exceedingly elevated suicide rate, even in the absence of alcoholism. This patient was prescribed complex pharmacotherapy. He remained symptomatic despite specialty care in the outpatient setting.  The patients medical condition was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. Further, the patient had failed intensive outpatient services and community programming. Considering the relevant peer-reviewed literature and current practice guidelines, service delivery at the residential level of care is safe, appropriate and consistent with good medical practice, and reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, inpatient drug and alcohol treatment is medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Epclusa  The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus . The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. For these reasons, Epclusa  is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for mental health residential treatment center (RTC) services for diagnoses of depressive disorder, not otherwise specified, borderline personality disorder and rule-out post traumatic stress disorder. She was not sleeping or showering, had an inconsistent life style, and was having mood swings. While at RTC, the enrollee received individual, family, and group therapy. Life skills were taught and practiced with the help of the transition specialist. In addition, she was seen for monthly psychiatric evaluations. The Level of Care Utilization System (LOCUS) guidelines were applied in this case. The enrollees composite LOCUS score is 18, which correlates with high intensity, community-based services. Medical evidence does not support the services at issue in this clinical setting. Therefore, the requested RTC services that were provided were not medically necessary for the treatment of this enrollee.Final Result: The physician reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil (Provigil). Findings:  The physician reviewer found that central hypersomnias are diseases manifested in excessive daytime sleepiness and that the Multiple Sleep Latency Test (MSLT) serves as an objective diagnostic method for idiopathic hypersomnias. The authors further note that for symptomatic therapy of excessive daytime sleepiness, the central nervous system stimulant modafinil seems to work well in most cases. In this case, the patient has a diagnosis of idiopathic insomnia based on MSLT results showing sleep latency of 3.5 minutes without sleep onset rapid eye movement (SOREM). In this clinical setting, the requested medication is medically indicated. Therefore, modafinil (Provigil) 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 sleep 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

The patient is a five-year nine-month old female with a history of developmental delays including expressive and receptive language delays. She has been receiving speech therapy since April 2005.  She has had various diagnoses including ADHD and autism.  Formal testing to demonstrate the diagnosis on the autism spectrum is not included in the information provided. Documentation from the therapist states the patient was evaluated at an autism clinic in January 2005, but she was not given a diagnosis of autism. The report goes on to state that a neurologist diagnosed the patient with a severe expressive language disorder and ordered an MRI and EEG.  No test results have been provided.  It is noted that the patients brothers also had speech and language delays.  At issue is whether continued speech therapy is medically necessary for the patients diagnosis.Based upon the documentation provided, the patients specific diagnosis is unclear (other than expressive and receptive language delay).  Three different therapists have provided reports for this patient. The goals are altered slightly with each evaluation, making it difficult to determine if the original goals have been achieved.  In any event, the goals listed are considered educational in nature. Given the absence of a clear diagnosis and the educational nature of the goals, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a breast MRI study for an evaluation of her breasts. Findings:  Three physician reviewers found that the standard evaluation for breast symptoms is diagnostic mammogram and breast ultrasound. This is true for patients with or without a history of breast cancer. Breast MRI is a useful adjunct to mammogram/ultrasound in select patient populations including those patients with new diagnosis of breast cancer. The use of breast MRI for screening purposes in patients with personal history of breast cancer continues to be controversial. At this time, breast MRI for screening purposes is limited to patients with BRCA mutation or strong family history of breast cancer. Breast MRI is not meant to replace mammography/breast ultrasound. In regard to this patient, breast MRI is not medically indicated at this time and would not be considered more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-two year-old woman with stomach bloating, poor digestion and irritable bowel syndrome is requesting reimbursement for a Heidelberg gastrogram and median stress assessment.  Reviewers Findings:The reviewing physician found that the details of the patients illness are not documented in the included materials and the complaints are quite broad and non-specific.  Also, these tests are of unproven efficacy and are not considered community standard of care.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested revision of the gastric sleeve for medical treatment of her gastritis, gastroesophageal reflux disease (GERD), hypertension, and sleep apnea.   Findings:  The physician reviewer found that some patients do fail to lose or maintain weight loss following sleeve gastrectomy. Based on the documentation provided, it is not clear that this patient has been compliant with diet and activity requirements following surgery. Overall, the patient specific causes that might lead to a failure of a second operation with durable weight loss have not been addressed. Given the absence of a more thorough assessment and documentation of compliance with a diet and exercise regimen, the requested revision of the gastric sleeve is not supported as medically necessary for treatment of this patients medical condition.