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

Nature of Statutory Criteria/ Case Summary: The parent of the enrollee has requested authorization and coverage for monthly Privigen (intravenous immune globulin) infusion therapy. The enrollee is diagnosed with selective immunoglobulin G (IgG) subclass deficiency, which his physician states is a primary immune disorder, and  Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Laboratory results revealed elevated assay markers for Ca/Calmodulin Protein Kinase II, and borderline assay markers for Anti-Dopamine receptor D-1 and anti-Tubulin. Laboratory results showed a low IgG level. The enrollees physician states that it is medically necessary for him to receive intravenous immunoglobulin (IVIG) therapy to maximize his protection against infection and without IVIG he remains at high risk for life threatening infections. The medical literature supports Privigen for the treatment of primary humoral immunodeficiency (PI), chronic immune thrombocytopenic purpura (ITP) in enrollees age 15 years and older and chronic inflammatory demyelinating polyneuropathy (CIDP) in adults. IVIG has been described in multiple case reports and case series. Results from a self-reported survey study provide some support for IVIG being perceived as an effective treatment for PANS.  IVIG has been tested in two double-blind trials, with the higher quality study indicating low support.  Therefore, the evidence for using IVIG is inconclusive and does not substantiate IVIG as an appropriate treatment as further studies are needed to support efficacy and appropriateness. Final Result: The reviewer determined that the requested therapy was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatrics and neurology with special qualifications in child 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services.  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) developmental, medical, substance use 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. This gives the patient a composite score which is consistent with medically monitored community based services. Due to their functional status score the recommended level of care is: medically monitored residence based services. Furthermore, the patient is scored at intermediate stay medically monitored residential programs. Per CALOCUS, these programs are sometimes referred to as short-term residential rehabilitation facilities and length of stay usually does not exceed 60 days. Thus, the first 60 days of treatment at the RTC were medically necessary for treatment of the patients condition. It was prudent to continue this level of care after the wilderness program, given patients recent gains and continued struggles, as well as family conflict. All told, a portion of the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested balloon sinuplasty for treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that this patient has reactive airway disease with history of asthma and chronic allergic rhinitis. These are not entities that will be cured by sinus surgery. Endoscopic sinus surgery, whether done with or without balloon instrumentation will not resolve congestion or rhinitis. It is not clear as to what medical therapy this patient has received and over what course of time.  It is recommended that patients with this type of disease undergo evaluation by an allergist in order to maximize medical therapy prior to considering surgical intervention. Consistent with these findings, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for vision care therapy for treatment of the enrollees vision problems.  Findings:  The physician reviewer found that Evidence based research demonstrates that vision therapy has a high success rate in the treatment and management of vergence dysfunction. Office-based vision therapy has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency. In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone. For these reasons, vision care therapy has been the method of choice for the treatment and management of convergence insufficiency and some accommodative anomalies. In addition, elimination of vergence dysfunction has been shown to improve reading scores. In this case, the patient has difficulty with completing reading tasks in addition to complaints of persistent headaches. For the reasons provided, the request for vision care therapy for the treatment of vergence dysfunction has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 optometry 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 53-year-old female with a history of hepatitis C, genotype 1 who received a 48-week course of Pegasys and ribavirin, but relapsed. She then received a full course of Infergen and ribavirin, but relapsed again. The patients provider has requested authorization for low-dose, Pegasys (interferon) maintenance therapy. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.There is, at present, no data to support the efficacy of maintenance interferon therapy. In fact, consideration of the toxicity, particularly bone marrow toxicity, and the cost would make this agent a poor choice for maintenance therapy. There is currently an on-going study (HACT-C) which may provide more information on the best course of treatment for patients such as this one, but for now Pegasys maintenance therapy cannot be considered medically appropriate. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old female with Barretts esophagus. Her last EGD was performed in May 2001 with biopsies demonstrating evidence of Barretts esophagus with no dysplasia. The patient has a first-degree relative who was diagnosed with esophageal cancer. The patient is requesting a capsule endoscopy for further evaluation.The Food and Drug Administrations approval criteria for wireless capsule endoscopy is quite clear and it is not approved for Barretts esophagus. Furthermore, there are no published, prospective, double blind studies in any peer reviewed journal showing the benefits of wireless capsule endoscopy in detecting and/or following Barretts esophagus. Wireless capsule endoscopy for this patient is not considered standard of care and is not the standard in the community.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old woman with hepatitis C who has been treated with Pegasys and Rebetol for 48 weeks. The patients provider has recommended prolonging the therapy past this point since some positive response was noted after the addition of amantadine. Apparently the patient failed the first therapy on 2001, relapsed in 2002, and attempted this regimen for a third time. The Health Plan has denied the patients request for continued treatment with Pegasys, Rebetol, and Procrit on the basis that the requested therapy is not medically indicated. The use of Pegasys in this patient with the above course of therapy is not the standard of care and is not medically indicated. Review of current medical literature reveals no adequate, prospective double-blinded studies involving non-responders who have relapsed after the next course of therapy. There is no conclusive data on whether such patients should be treated again, and if so for how long. Since continued treatment with Pegasys and Rebetol is not medically indicated, there is no medical justification for the use of Procrit. Therefore, 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: Medical Necessity
Decision: Overturned

A male enrollee requested the Quickie Iris SE manual wheelchair and accessories (HCPC E1161 x 1, K0108 x 11 ALL, E0973 x 2, E2213 x 2, E2206 x 1, E2609 x 1, E0978 x 1, E0956 x 4 ALL, E2671 x 1, E1028 x 4 ALL, E0960 x 1, E0955 x 1 and E0957 x 1) for medical treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history of cerebral palsy and developmental delay resulting in severe impairments in self-care and mobility.  The patient requires a specialized seating system on an ongoing basis and a tilt-in-space positioning system in his mobility device to optimize pressure relief and mitigate the risk of pressure sores.  In addition, he has a history of seizure disorder and has had a fall from his wheelchair, which underscores the need for a supportive and stable type of mobility device.  His current wheelchair is in a state of disrepair and no longer fits him adequately.  All told, the requested Quickie Iris SE manual wheelchair and accessories are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee has requested a cardiac positron emission tomography (PET)  for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the medical records provided for review demonstrate that the patient presented with risk factors for coronary heart disease. Cardiac PET scans may identify early functional and/or structural abnormalities of the coronary artery circulation before its progression to symptomatic coronary artery disease ensues (Schindler, et al). According to Hendel and colleagues, newly diagnosed heart failure with left ventricular (LV) systolic dysfunction represents a high coronary heart disease risk and is rated 7 on a 1-9 scale of appropriate indications for radionuclide imaging and is considered appropriate use of this technology. Moreover, cardiac PET scans have a high accuracy and a low dose of radiation exposure (Schindler, et al). Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the services at issue has been established in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld

A 26-year-old male enrollee has requested for emergency services for treatment of his abdominal pain.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and one hour of moderate (5/10) abdominal pain associated with one episode of diarrhea would not reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. An article by Myers and colleagues recommends a comprehensive educational program to include speech therapy for children with autism spectrum disorder (ASD). In this case, the patients scores show continued maintenance of her language skills and some improvements with age, but not improvements beyond what would be expected based on time passing. Per a recent speech therapy evaluation, the patient currently receives speech therapy services through the school district. The Health Plans recommendation of continued speech therapy services through the school district is medically reasonable and appropriate in this clinical setting. For the reasons stated, speech therapy services are not medically necessary in this clinical setting. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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

This patient is a 24-year-old female who had moderate to severe plaque psoriasis covering 20% to 25% of her body surface area. UVB therapy and various topical, prescription, psoriasis medications have not been effective. The patient has a strong family history of kidney disease and reportedly plans to become pregnant within three years. Since she began treatment with Enbrel in May 2006 her psoriasis has improved to the point where it covers only 1% of her body surface area. As of August 2006 the Enbrel dosage has been reduced to 50mg every other week. The patient now requests reimbursement and on-going coverage for further treatment with Enbrel. The Health Plan does not consider the medication medically necessary and has denied authorization and coverage.The patient has a strong family history of kidney disease, hypertension and liver disease which places her at a higher risk for developing these conditions. As such, treatment with methotrexate and cyclosporine is contraindicated. The patient is also in her child-bearing years and expresses a desire to become pregnant in the next three years. Soriatane should not be prescribed under these circumstances. The patients treatment with Enbrel is medically indicated and has resulted in significant improvement. The treatment should be continued under the supervision of her provider. 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breasts for evaluation of her medical condition.  Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. In this particular patient, the presenting symptom is breast pain. Her prior MRI performed on the date indicated did not reveal any signs of malignancy, and she has no reported palpable lumps. Breast pain is rarely associated with breast cancer, especially without a recognizable mass. As noted by Howard and colleagues, Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. Finally, an MRI is clinically necessary as a problem solving tool, however in this case, the MRI study was ordered at the same time that the mammogram and ultrasound were ordered and there is no indication that a repeat mammogram revealed suspicious findings. Thus, the request for MRI of the breasts is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female with diabetes.  The record indicates that she injects Lantus and Novolog insulin four times a day. The dose of both types of insulin is not documented nor is there documentation of any oral medications used to control her diabetes. The patient appears not to have long-term complications or hypoglycemic unawareness.  The blood sugar log kept by the patient from August 2005 through November 05 shows close to adequate control. There are two morning blood glucose levels of 60 and a few of over 200.  In May 2005 her hemoglobin A1C was 7.1%. In September 2005 the patient had a blood glucose of 311 recorded by the lab and her hemoglobin A1C was 9.2%.  There is no recent hemoglobin A1C recorded. There was a period of time from the end of August until early September that the patient did not inject Lantus insulin for two weeks without a notable change in her daily glucose values.  The patient has requested authorization for an insulin pump, which was denied by the Health Plan as not medically necessary.In general, there are standard criteria for insulin pump eligibility: Type I diabetes mellitus, poor control on a regimen of multiple injections, severe blood glucose fluctuations, hypoglycemic unawareness and long-term complications.  The patient indicated that she had Type II diabetes. There is no C-Peptide level documented, so it is assumed that the patient is correct and she does not have Type I diabetes. Her blood sugar levels off of Lantus insulin did not differ from those recorded when she was using Lantus.  Over a three-month period of time she had very few low blood sugar levels, and a small number over 200.  There is no mention of hypoglycemic unawareness or long-term complications of diabetes in the record. The patient appears to be fairly well controlled on her present course of diabetic management.If there is documented evidence the patients C-Peptide level is low (less than 0.9) the patients request should be reconsidered.  Based upon a review of the record provided, this patient does not meet the criteria for an insulin pump.  Therefore, I have determined the requested device is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings: The physician reviewer found that TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. The general treatment course for TMS includes 30-40 sessions delivered over a course of 4-6 weeks. In cases where a positive response is achieved, oral medication and psychotherapy are typically utilized to maintain remission.  In this case, the patient had a positive response to an adequate course of TMS and was tapered from the intervention. The patient was not prescribed oral prophylactic psychotropic medication aside from an antianxiety agent.  The records do not document that the patient was active in psychotherapy. The patient reported increased anxiety, and vomiting in the morning because of his anxiousness. Although he denied depression, TMS was resumed at a frequency of 1-2 times per month. The medical records do not demonstrate that standard therapies have been exhausted. Considering that TMS is not approved for anxiety and the standard remission enhancing strategies of pharmacotherapy and psychotherapy were not employed, the medical evidence does not support the medical necessity of TMS therapy.  Final Result: The reviewer determined that the services at issue were not and 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 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 twenty-nine year-old male diagnosed with idiopathic hypersomnolence is requesting reimbursement for the cost of Provigil.Reviewers Findings:The reviewing physician found that the consulting neurologist did not eliminate Provigil as a treatment option, he clearly indicated it was not the healthiest option.  Also, the patient does not meet typical criteria for Provigil.  The physician concluded that the Health Plan denial should be upheld.