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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1b. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high quality clinical trials showing cure rates of over 90% and safety and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for implant nerve stimulator surgery. Craniofacial pain is difficult to treat and can have severe implications for patients with this condition. Craniofacial pain includes trigeminal neuralgia, trigeminal neuropathic pain, and persistent idiopathic facial pain. This patient presents with craniofacial pain. The patients provider has recommended treatment with an implanted nerve stimulator. Early results are promising and neurostimulators have demonstrated efficacy in small patient cohorts with a variety of craniofacial pain states. This patient sustained a left orbital blowout fracture and he presents with left-sided facial pain. All told, the requested implant nerve stimulator surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested for residential rehabilitation treatment for treatment of her polysubstance abuse. Findings:  The physician reviewer found that APA substance treatment guidelines state that patients who step down to a partial day hospitalization program (which is the next least restrictive setting after the RTC level of care) do require intensive care, but that they have a reasonable probability of refraining from illicit use of substances outside of a restricted setting (see Kleber).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for percutaneous transcatheter patent foramen ovale (PFO) closure. Current peer-reviewed medical literature has demonstrated that transcatheter PFO closure is more effective for preventing recurrent ischemic stroke than antiplatelet therapy alone for well selected patients who have an embolic-appearing cryptogenic ischemic stroke and a PFO. For patients with a cryptogenic embolic-appearing ischemic stroke who have a PFO and no other evident source of stroke despite a comprehensive evaluation, data supports transcatheter PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. The studies report a greater benefit of closure in patients with a large right-to-left shunt or an associated atrial septal aneurysm. This recommendation applies to patients who place a higher value on the moderate absolute stroke risk reduction of PFO closure and a lower value on the burdens and harms associated with device placement. Based on the available records, this patient has an atrial septal aneurysm and a right-to-left shunt. Thus, the requested percutaneous transcatheter closure of PFO is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested percutaneous transcatheter closure of PFO is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested percutaneous transcatheter closure of PFO is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology and is 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested authorization and coverage for a posterior decompression from C3-T1 with lateral mass screws extending down to T2 for treatment of the enrollee, who is status post anterior cervical discectomy and fusion from C4-C7 and posterior spinal fusion from L3-L5. Findings:  The physician reviewer found that the current medical evidence does not support the requested procedure in this clinical setting.  Decompression of the spinal cord is indicated for the treatment of appropriate patients with myelopathy.  However, surgery should be a treatment of last resort and should be performed only after the failure of conservative measures.  At this time, it is unclear whether the short-term risks of surgery are offset by the benefits, and further research is needed to clarify the problem.  In this patients case, there is limited documentation of the presence of neurologic deterioration, with little change in findings noted.  In addition, there is a lack of documentation regarding radiographic worsening.  All told, the requested posterior decompression from C3-T1 with lateral mass screws extending down to T2 is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment center services provided for treatment of his behavioral health condition.  Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, there is a lack of evidence demonstrating acute withdrawal symptoms, or evidence showing the patient to be a danger to himself or others. He had no comorbid psychiatric or medical conditions. He was not psychotic or manic. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant this level of care. He presented for admission volitionally, demonstrating a degree of motivation for change and level of awareness. Although he smoked cannabis daily he was willing to relinquish his medical cannabis card. He was a binge user, his last use was two days prior to admission. He participated in his treatment plan. He planned to go to a sober living environment. Based on the documentation submitted for review, the patient could have been treated at a lower level of care such as intensive outpatient program (IOP), in conjunction with community support in the form of a 12-step program along with a sponsor and counseling. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition.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 sub-specialty certification in addiction 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

This patient is a 25-month-old female with a history of global developmental delay, esotropia, ptosis, hyperopia, and hypotonia.  She is status post a strabismus surgery and surgery to correct the ptosis. She wears glasses. She also has severe receptive and expressive language delays. The patient has been receiving speech therapy since April 2006. At issue is whether speech therapy is medically necessary for the patients developmental delays.Review of the relevant literature reveals no evidence to support that the patients vision issues are or can be a direct cause of speech delay. Rather, it appears the speech delay is part of a constellation of deficits associated with global developmental delay. Furthermore, no medical evidence from the patients ophthalmologist, geneticist or a pediatric neurologist is provided documenting that the speech deficits are associated with a disease, trauma or prior therapeutic intervention. The documentation from the speech therapist does not demonstrate the expectation that speech therapy will achieve measurable improvement in the patients condition in a reasonable and predictable period of time. Based on the information in the submitted reports the patients progress has been minimal and it does not appear likely that improvement will be seen in a reasonable and predictable period of time. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for the following branded prescriptions: Strattera 40 mg capsule, two times a day; Intuniv 4 mg tablet, one a day; and Abilify 30 mg tablet, one a day. The U.S. Food and Drug Administration has approved the use of Abilify to treat irritability associated with autistic disorder and agitation associated with bipolar mania, and has approved the use of Intuniv and Strattera to treat ADHD. LeClerc and Easley noted, Medications are often added to behavioral therapy to help patients with autism spectrum disorder function successfully.  In this case, the patient is clinically stable on her current medications. It is medically appropriate for the patient to continue with her current regimen. Therefore, branded prescriptions for Strattera 40 mg capsule, two times a day; Intuniv 4 mg tablet, one a day; and Abilify 30 mg tablet, one a day are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 53-year-old female enrollee has requested emergency services for treatment of her pain.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with left buttock and left leg pain that had been ongoing for three months. Although the patient rated the pain as an 8/10, there was no acute exacerbation of pain or any new neurologic deficits. Moreover, a physical examination did not reveal any acute neurologic deficits or indication for emergent imaging. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  Three physician reviewers found that based on the submitted records, this patient presented with increased coronary risk and coronary artery disease.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, myeloperoxidase, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other available options for evaluating this patient. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested Sovaldi, ribavirin and peginterferon for treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that patients with advanced fibrosis or compensated cirrhosis are among the highest priority for treatment. The medical necessity of the proposed Sovaldi, ribavirin and peginterferon is not recommended in treatment-naive HCV patients with the patients characteristics.  In this case, the patient is interferon-ineligible based on his history of depression. In addition, he fails to meet the AASLD and IDSA definition of High Priority or Increased Risk for treatment. All told, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the patient was experiencing some physical discomfort on admission. His mental status exam showed loosening of associations and paranoid thinking. He was irritable and agitated, and with the history of bipolar disorder. The night before admission he had threatened violence against his girlfriend and experienced thoughts of self-harm. Although on admission he denied suicidal or homicidal ideation, these are issues which should not be treated lightly especially given his agitated state. On admission he did demonstrate emotional, behavioral, cognitive, and impulsive symptoms that warranted this level of care. He was medically stable but he was not psychiatrically stable. He was significantly calmer and showed no agitation. He was cooperative and participating in the program and groups. He was compliant with taking his Seroquel. There was no evidence of suicidal or homicidal ideation. He could have been stepped down to a lower level of care. 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 sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for Fisher Wallace Cranial Electrical Stimulator (transcutaneous electrical nerve stimulation (TENS) device). Findings:  The physician reviewer found that Fisher Wallace Cranial Electrical Stimulator may be appropriate for patients with intractable depression. However, this device is not intended for myofascial pain, chronic pain syndrome, or chronic insomnia. In this case, there is no evidence of refractory depression given the lack of documentation that the patient had been tried on, and failed, multiple antidepressants. In addition, the patient indicated that CBT was helpful for insomnia. All told, the requested Fisher Wallace Cranial Electrical Stimulator (transcutaneous electrical nerve stimulation (TENS) device) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Urine PCR test in order to evaluate for Lyme disease and co-infections. This patient is at low risk for active Lyme disease. Prior evaluation has included multiple negative Lyme tests. As noted in the medical literature, the accepted Lyme testing strategy includes antibody and Western blot analysis. The current data does not support an indication for Urine PCR testing in this clinical setting. For those reasons, the requested Urine PCR test is not medically necessary for evaluation and management of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a full 28-day partial hospitalization program (PHP) at a facility that specializes in obsessive-compulsive disorder (OCD) and utilizes Exposure and Response Prevention (ERP) therapy. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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. Based on the records provided for review, this patient is at moderate risk of harm (score 3) due to past and current self-harm as well as reports of suicidal ideation. The patients functional status is seriously impaired (score 4) due to inability to complete activities of daily living  as well as inconsistent eating due to mental illness. The patient presents with no serious medical, addictive or psychiatric comorbidity (score 1) due to overall medical stability and no mention of substance use. The patients recovery environment is mildly stressful (score 2) but includes a stable living situation. His recovery environment is supportive (score 2) due to family support and availability of treatment resources. The patients treatment and recovery history has been poor (score 4) is due to minimal past treatment response and failure to maintain symptom resolution. He appears to have recalcitrant symptoms that have been difficult to control. The patients treatment history includes residential treatment, ECT, and recent inpatient psychiatric care. The patients engagement in treatment has been limited (score 3) due to fair cooperation in treatment and poor insight into his need for treatment. This provides a composite score of 19, which correlates with medically monitored residential services. As this score supports PHP level of care and the patients condition has been resistant to standard therapies, a full 28-day PHP at a facility that specializes in OCD and utilizes ERP is medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.