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

The patient is a 17-year-old female with previously diagnosed dysthymic disorder, oppositional defiant disorder, and borderline intellectual function The patient was previously psychiatrically hospitalized in March and July of 2003 due to increasingly aggressive behavior and anger outbursts. A review of past records indicates anger and insubordination have been ongoing problems since the age of three, but have grown measurably in adolescent years. This has included unprovoked choking of her sister, shoving family members, non-compliance with rules at home and at school, lying, stealing, and killing cats, all of this without remorse. The patient later claimed some of her actions such as the killing of the cats were spurred by voices, typically that of a man, urging her to do so. However, in reporting her actions the patient was noted as matter-of-fact, only later adding that she was trying to break the habit of animal murder. Some of her aggression has also varied between parents.  Typically, the patient is more compliant with her adopted father than with her adopted mother. Other problematic behaviors have included some fire setting at home, intrusion into other peoples space, and loud speaking. An evaluation by her social worker reports the patient herself feels that she has no guilt or remorse, will do anything to get what she wants, has no regard for consequences, is aggressive, and plays one person against another. The hospital records from the patients prior two admissions do not indicate that residential treatment was necessary. At issue is whether residential psychiatric treatment services are medically necessary for treatment of the patients medical condition.While the patient may be suffering from dysthymic disorder and perhaps even bipolar disorder, she seems to have a fairly pronounced conduct disorder, rather than simply oppositional defiant disorder. It appears there is premorbid genetic loading for conduct disorder, given what is known about her biological parents pathology. Her actions are certainly egregious and of concern. However, none of the psychiatric records point to the patients symptoms being so robust as to warrant residential treatment. Out of home placement may be an option for the patient, given what is known about her behavior in the context of her adoptive mother versus that with her adopted father; however, this should not be confused with a need for residential treatment per se. As reflected in the patients psychiatrist note of 8/14/03, the patient does not require the level of structure found on a residential unit. Importantly, no up-to-date clinical information has been submitted to support the request for residential treatment. In the absence of such information, residential treatment cannot be supported.Based upon the information set forth above, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly intravenous infusions of vitamin C. Findings:  The physician reviewer found that (FDA) notes that ascorbic acid, vitamin C, injections may be indicated for the treatment of scurvy and is not indicated for treatment of vitamin C deficiency that is not associated with the signs and symptoms of scurvy. Nauman and colleagues report that while vitamin C has promising results as a potential treatment for cancer as an independent agent and in combination with standard chemotherapies, further randomized placebo-controlled trials such as the ongoing placebo-controlled trials of vitamin C and chemotherapy in prostate cancer are needed. In this clinical setting, given that current medical literature does not support the use vitamin C in the treatment of prostate cancer outside of a clinical trial, the requested service is not medically indicated. Therefore, weekly intravenous infusions of vitamin C are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology 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 and prospective authorization and coverage for residential treatment center services provided. Findings:  The 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 those with serious addiction and comorbid mental illness. In this case, the patients substance use was dominating daily routine and causing functional impairment across multiple domains.  The patient has chronic, serious addictive illness. The patient was using intravenous heroin, consuming alprazolam and ingesting an opioid plant material, heroin and cocaine. The patient had a comorbid psychiatric diagnosis of generalized anxiety disorder and a poor self-concept. The patient had recently failed two successive supervised detoxifications. Thus, a conservative residential treatment stay was indicated. A review of the record, indicates that the patient was struggling with anxiety, depression, shame and craving around the time of service denial. It appears that the services have helped with the consolidation of treatment gains while developing a transition plan for treatment in a less restrictive setting. Based on the longitudinal history and medical documentation, the patient would promptly relapse and require re-admission in the event of a premature discharge from residential programming. Thus, the services and setting are safe, appropriate and consistent with good medical practice. Further, the services provided have been for active treatment delivered in accordance with a treatment plan, and are reasonably expected to bolster his resilience, improve his condition and prevent a more serious episode of illness. Final Result: The reviewers determined that the services at issue were and are 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: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for diclofenac 3% gel. This patient is being treated for meniscal tear in right knee and right knee osteoarthritis. MRI of the right knee demonstrated a complex tear of the medial meniscus, discoid lateral meniscus complex, and chondral degenerative changes. The patients provider has recommended treatment with diclofenac 3% gel. Regarding the use of topical nonsteroidal anti-inflammatory drugs (NSAIDs), Barkin stated, NSAIDs are widely used in the treatment of pain associated with a variety of indications, including arthritic conditions, but their usefulness is often limited by dose-dependent adverse events (AEs), such as gastrointestinal disturbances, cardiovascular events, and renal toxicity. The risk of such effects could be reduced by the use of topical formulations, which offer the potential to deliver analgesic concentrations locally, at the site of inflammation, while minimizing systemic concentrations. The topical preparations currently approved in the United States are diclofenac sodium 1.5% topical solution (containing dimethyl sulfoxide as a penetration enhancer), diclofenac sodium gel 1%, and a diclofenac hydroxyethylpyrrolidine 1.3% patch. Each of these topical NSAIDs provide drug delivery to subcutaneous tissues for the management of pain associated with osteoarthritis or soft-tissue injuries. In addition, Derry and colleagues reported, Topical NSAIDs provided good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to the results provided by oral NSAIDs. However, in this case, the provider has requested the use of diclofenac topical gel 3%. This diclofenac formulation is U.S. Food and Drug Administration (FDA) approved only for the treatment of actinic keratosis, which is a precancerous lesion of the skin. There is a paucity of published large-scale, long-term peer-reviewed medical literature demonstrating that diclofenac 3% gel is effective and safe for the treatment of patients with osteoarthritis. All told, the requested diclofenac 3% gel is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested  speech therapy services and continued speech therapy services at a frequency of one time per week (one hour each session) for treatment of his delays in receptive, expressive and social language skills.  Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator.  There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these children. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, social skills training, and behavioral therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language.  As noted by Volkmar, most children with autism spectrum disorder will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Children on the autistic spectrum have deficits in speech and language, as well as social communication. Therapists with experience working with children with autism spectrum disorder, handling the myriad of communication challenges that face these children, are most appropriate. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. All told, the submitted documentation demonstrates the medical necessity of speech therapy services provided during the said time frame. Additionally, continued speech therapy services at a frequency of one time per week (one hour each session) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for mastectomy to remove breast tissue for treatment of the enrollees gynecomastia. Findings: The physician reviewer found the submitted documentation supports the medical necessity of the requested services. The records document evidence of significant asymmetric gynecomastia that has been present for an extended period of time. This has affected him psychosocially as supported by his treating neuropsychologist. His work-up has included a history and physical examination, as well as excluding some of the more common etiologic sources. Based on the documentation provided, the patient has feminization of the breasts and marked breast enlargement consistent with grade IV gynecomastia. The American Society of Plastic Surgeons (ASPS) lists indications and recommendations for insurance coverage. Per ASPS, surgical treatment of gynecomastia in adolescents is recommended in the following settings: unilateral or bilateral grade II or grade III gynecomastia present which persists more than one year after pathological causes are ruled out; unilateral or bilateral grade IV gynecomastia present which persists more than six months after pathological causes are ruled out or persists after six months of unsuccessful medical treatment for pathological gynecomastia; and pain and discomfort due to the distention and tightness from the hypertrophied breast. Gynecomastia may cause considerable psychological distress, especially in adolescents who are struggling with issues related to sexual identity and self-image. This patient has evidence of grade IV gynecomastia that has been present for an extended time and has evidence of significant psychological distress directly related to his gynecomastia. Additionally, likely correctable etiologic sources have been ruled out. Thus, the medical evidence supports the requested services in this clinical setting. All told, the requested mastectomy to remove breast tissue 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 82172 and 83695). The records document that this patient has mild, subclinical atherosclerosis as seen on radiologic studies. She is at intermediate 10-year risk for symptomatic cardiovascular disease and is being treated with statin and aspirin therapy. Her low-density lipoprotein (LDL) cholesterol is close to goal on a low dose statin and her high-density lipoprotein (HDL) is high. As she has some mild but established vascular disease and hypertension treated with statin therapy. Advanced lipoprotein testing may be considered for additional cardiovascular risk evaluation when  a patients cardiovascular risk is borderline or intermediate. In this case, the patient has mild but established vascular disease and is already being actively treated with statin therapy (Arnett, et al.). Additional measurements with advanced lipid profiles do not change the guideline-directed therapeutic plan of treating to appropriate LDL goals with statin therapy. Accordingly, the advanced lipoprotein testing (CPT 82172 and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 82172 and 83695) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested for pulmonary vein isolation/catheter ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that most cases of atrial fibrillation can be managed effectively with rate control and anticoagulation, or with pharmacologic antiarrhythmic suppression and anticoagulation. However, rare patients,  remain very symptomatic even with the best medical management strategies. Ablation procedures are appropriate, even though they may require repeated ablation attempts, in this particular subset of patients.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested CyberKnife stereotactic body radiation therapy (SBRT) for treatment of his prostate cancer. Findings:  Three physician reviewers found that according to the current National Comprehensive Cancer Network (NCCN) guidelines, the standard of care would be either radical prostatectomy or radiation therapy. The NCCN also suggest that 3D conformal and intensity modulated radiation therapy (IMRT) technique should be employed, given in conventional fractions while image guided radiation therapy (IGRT) is required if dosing exceeds or equals 78 Gy. Furthermore, the criteria state that in patients with intermediate risk disease, doses between 78-80 Gy have been shown to provide improved PSA-assessed disease control. However, the guidelines do not mention SBRT given at 7.25 Gy given in 5 fractions either alone or as a boost for prostate cancer patients. Patients also with intermediate recurrence risk may also be considered for short-term neoadjuvant/concomitant/adjuvant androgen deprivation therapy. Overall, there is a paucity of data establishing SBRT as likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy as outlined in current NCCN practice guidelines for prostate cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 49-year-old male enrollee has requested authorization and coverage for Vemlidy. Findings:  The physician reviewer found that : guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared with alternatives for the treatment of chronic hepatitis B . In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. 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

A fifty-four year-old female with leg pain associated with varicose veins is requesting authorization of sclerotherapy.  Reviewers Findings:  The reviewing physician found that the patients symptoms meet the above criteria, but there is no documentation of conservative therapy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The advantage of tomosynthesis is the ability to often separate dense underlying glandular tissue from mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers. Although there is a lack of long-term studies showing an increased survival rate when tomosynthesis has been added to the usual two-dimensional (2D) views, tomosynthesis was likely of more benefit to the patient than had the exam been done with 2D imaging only. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested a portable oxygen concentrator for the treatment of his respiratory failure. Findings:  The physician reviewer found that this patient has respiratory failure requiring continuous oxygen and oxygen with exertion. It has not been made clear why he is unable to use an E-tank oxygen cyclinder (E-tank) for his exertional projects. As long as the patient is supplied with a sufficient number of E-tanks, his needs can be met. There is rarely any medical necessity for a portable oxygen concentrator. Though more convenient, there is no medical indication for the proposed portable oxygen concentrator. Thus, the evidence is not sufficient to justify the medical necessity of the portable Inogen One Concentrator.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested for partial hospitalization program services for treatment of his behavioral health condition. Findings:  The physician reviewer found that based on the documentation provided, there is inadequate support for additional PHP services at this time. This determination is based on and consistent with this patients clinical condition as applied to Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services criteria and American Psychiatric Association guidelines.