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

An enrollee has requested authorization and coverage for 5 days a week of Intensive Outpatient (IOP) level of services. Studies have demonstrated higher rates off depression with patients who have chronic health problems including diabetes. Coexisting depression in people with diabetes is associated with decreased adherence to treatment, poor blood sugar control, higher complication rates, decreased quality of life, increased healthcare use and cost, increased disability and lost productivity, and increased risk of death. Depression increases risk of health problems and poor treatment adherence, and there is a bi-directional relationship between diabetes and depression. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The enrollees composite score indicates that the patient qualifies for a High Intensity Community Based Services level of care. High Intensity Community Based Services serve treatment needs that require contact several times per week. The patient has many risk factors as well as worsening diabetic control in the setting of her binge eating and co-morbid mood instability. If the patient does not continue in the structure of an intensive outpatient setting, she is likely to continue to gain weight, have poor medication adherence, and be at risk of further health complications. A High Intensity Community Based Services level of care is consistent with the requested 5 days a week of Intensive Outpatient (IOP) level of services. Therefore, 5 days a week of Intensive Outpatient (IOP) level of services is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two acupuncture treatments per week for the first six weeks and one acupuncture a week for eighteen weeks. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested services in this clinical setting. The patient has many conditions that are commonly helped by acupuncture treatment. However, she has had an unknown total amount of acupuncture in the past with at least 11 sessions within the last year with no improvement in her condition. The request for thirty acupuncture treatments is not supported by medical evidence. Most studies for acupuncture recommend short term treatment.  For example, acupuncture is an effective short term treatment for patients with chronic neck pain, but there is limited evidence for long term effects. For chemotherapy-induced nausea and vomiting, results of 11 trials differed according to modality with acupressure appearing effective for first day nausea, electroacupuncture appearing effective for first day vomiting, and noninvasive electrostimulation appearing no more effective than placebo for any outcome. Also, studies show that acupuncture is not clinically significant than sham-acupuncture or placebo for neck pain. Studies for low back pain are generally limited to approximately 12 sessions over the course of eight weeks.  There is limited evidence for extended treatments over the course of approximately half a year. The patient has had short term treatment for her condition with at least 11 sessions in the past year. The records do not demonstrate that these treatments have provided improvements. As such, acupuncture treatment twice a week for six weeks and then once a week for 18 weeks are not medically necessary for treatment of this patients medical condition. 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 oriental 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: 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 current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis offers advantages to radiologists reading mammograms, especially in women with heterogeneously and extremely dense tissue.  This new technique often allows the reader to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in biopsies, increase in detection of small cancers and decrease in callbacks.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional mammographic imaging protocol was likely of greater benefit to the patient than had she had the examination with two-dimensional imaging alone.  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 physician 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 29-year-old female enrollee has requested modafinil for treatment of her idiopathic hypersomnia.  Findings:  The physician reviewer found that currently, modafinil is not supported for treatment of this patients idiopathic hypersomnia (Billiard and Dauvilliers). The patient would be better treated with other stimulants which are likely to be more effective including Ritalin and Adderall. Overall, the records provided for review do not indicate the patient has already been treated with a stimulant, or that she has a contraindication to these standard alternatives. Consistent with these findings, the requested medication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 19-year-old female who is being evaluated for splenomegaly. In December 2005 she underwent a CT of the abdomen and pelvis due to abdominal pain. This exam showed splenomegaly and pericholecystic fluid.  The patient was diagnosed with cholecystitis and had a laparoscopic cholecystectomy.  The etiology for the splenomegaly is now being investigated. The patient also has several relatives with hereditary spherocytosis.  The patients provider requested authorization for a PET scan to further evaluate her splenomegaly.  The request was denied by the Health Plan based on a determination that the diagnostic procedure was not medically necessary.The differential diagnosis for splenomegaly is quite long and includes malignant and benign and infectious and non-inflammatory etiologies.  The results of a PET scan will do little towards reaching a definitive diagnosis.  In addition, splenomegaly without a specific etiology is not an approved indication for PET scan by the Centers for Medicare and Medicaid Services (CMS).  Therefore, I have determined the requested diagnostic 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

A 44-year-old male enrollee has requested magnetic resonance imaging (MRI) of the cervical spine for evaluation of his cervical disc disorder with radiculopathy.   Findings:  The physician reviewer found that based on a review of the available records, this patient has had cervical spine pain for at least a couple years following a motor vehicle accident. Plain film x-rays are referenced in the physical exam but no report is in the records provided for review. There is no neurological deficit noted on exam and no atrophy or weakness is described in the providers notes. In addition, the patients deep tendon reflexes are normal. There are no red flags to provide an indication for a cervical spine MRI. Thus, the requested MRI of the cervical spine is not medically necessary for further evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM test. Findings:  The physician reviewers found that the DecisionDx-UM test evaluates the genetic profile of an individual patients uveal melanoma tumor sample to determine the patients risk for metastasis. The DecisionDx-UM test stratifies a tumor to low risk and high risk for metastasis and is considered the current standard of care. Although it does not change the prognosis, it does provide prognostic information that is clinically useful. As this testing is within the standard of care for patients with uveal melanoma, the DecisionDx-UM test rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-UM test rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 36 hours per week of direct applied behavioral analysis (ABA) therapy and 14 hours per month of supervision provided. Findings:  The physician reviewer found that In this case, the medical necessity of ABA services has been established. The correlation between treatment outcomes and treatment intensity is well documented. Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD).  Research studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Moreover, several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. In this case, the patient appears to have made progress, but continues to have significantly problematic behaviors. The patient continues to struggle with stereotypic behavior at a high rate, and her outburst behaviors also continues to be problematic. While the patient appears to have made progress, she continues to demonstrate impairment in several areas at a high frequency making it increasingly difficult for her to be successful in more generalized environments. Accordingly, 36 hours per week of direct ABA therapy and 14 hours per month of supervision provided from date of dispute and forward were and are medically necessary in this clinical setting. Final Result: The reviewer determined that 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: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 18-year-old female who was evaluated by a plastic surgeon for symptomatic mammary hypertrophy. The patient reported back, neck, and shoulder pain related to heavy, pendulous breasts and had demonstrated bilateral shoulder grooving. The patients plastic surgeon has recommended bilateral breast reduction surgery. The Health Plan has denied authorization and coverage for breast reduction surgery on the basis that it is not medically necessary given the amount of tissue that is to be removed.Although the patient is somewhat young, there have been documented physical findings associated with mammary hypertrophy and symptoms of back and neck pain. The patient has not had the problem long enough to have developed the permanent skin changes associated with repeated/constant intertrigo but such changes are likely to occur. Symptomatically, the procedure is medically indicated. According to the American Society of Plastic Surgeons guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the submitted clinical information and photographs demonstrate that breast reduction surgery is medically indicated. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, although this patient discontinued Sovaldi and ribavirin due to adverse effects, Epclusa for 12 weeks is also appropriate for non-cirrhotic patients who have failed Sovaldi and ribavirin, based on near-complete cure rates in this group in the POLARIS-4 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 representative of a 23-year-old male enrollee has requested a referral to receive hypnotherapy for treatment of his intellectual disability and compulsive eating of non-food items.  Findings:  The physician reviewer found that based on review of the available records, this patient has a history of developmental disabilities and Pica and was referred for hypnotherapy to treat his eating disorder. The current medical literature on the treatment of eating disorders does show that hypnotherapy can be effective for weight loss. The confounding factor in this patient is that he suffers from mental deficits in addition to his eating disorder and the data is less clear in this patient subset. In fact, there is inadequate data demonstrating the effectiveness of hypnotherapy in a patient with cognitive impairment. There are many articles using various minerals including zinc and iron as well as pharmacotherapy for the treatment of Pica. This patient had been tried on medication but its use was discontinued secondary to side effects. Given the availability of conventional, proven treatment alternatives in treating this patients eating disorder, the medical necessity of the requested hypnotherapy has not been established in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for home birth with a certified nurse midwife. According to the American College of Obstetricians and Gynecologists (ACOG), hospitals and accredited birth centers are the safest settings for birth. Although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with increased risk of perinatal demise, seizures, and serious neurologic dysfunction. There is a lack of adequate randomized clinical trials of planned home birth. In developed countries where home birth is more common than in the U.S., attempts to conduct such studies have been unsuccessful, largely because pregnant women have been reluctant to participate in clinical trials that involve randomization to home or hospital birth. Consequently, most information on planned home births comes from observational studies, which are limited by methodological problems. Some recent observational studies overcome many of these limitations, describing planned home births within tightly regulated and integrated health care systems, attended by highly trained licensed midwives with ready access to consultation and safe, timely transport to nearby hospitals. However, these data may not be generalizable to many birth settings in the U.S., where such integrated services are lacking. In this case, it is important to consider that the patient is also in a high-risk category. Typically, providers more carefully monitor women over the age of 35 to ensure the safety of the fetus and for delivery-associated complications in this higher risk population. All told, the requested home birth with a certified nurse midwife is not medically necessary for 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee has requested for a MRI of the brain for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that an MRI of the brain is standard procedure before starting growth hormone therapy to rule out cystic lesions.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested authorization and coverage for upright magnetic resonance imaging (MRI) with flexion/extension and a 3D computed tomography (CT) scan with rotational views. In this case, supine flexion/extension MRI of the cervical spine and dynamic radiographs have been recommended and performed yielding essentially normal results. All of the patients imaging and physical examination findings to date have not shown evidence for ligamentous instability at the craniocervical junction. Furthermore, upright MRI and CT with rotational views are not necessary for further evaluation of the patients symptoms, as she has already undergone extensive imaging of the brain and spine which have yielded essentially normal results. Therefore, the requested upright magnetic resonance imaging (MRI) with flexion/extension is not medically necessary to treat the patients medical condition. In addition, the requested 3D computed tomography (CT) scan with rotational views is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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: Overturned

A 46-year-old female enrollee has requested for Avastin/Ixempra combination therapy for treatment of her metastatic breast cancer.   Findings:  Two physician reviewers found that Avastin is a humanized monoclonal antibody targeting VEGF. It is approved in colon, lung, and breast cancers. In breast cancer it is specifically approved for front line use with Paclitaxil, although it has been studied in other settings. Many questions remain regarding the optimal use of Avastin, including optimal duration of therapy and multiple lines of therapy. These questions will likely never be answered by Phase III clinical trials. The treatment with the highest probability of efficacy would be an Avastin-containing regimen.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for the Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that Oncotype DX is a 21-gene assay that has proven to be a reliable and valid predictor of the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. This test is widely accepted by the oncology community for patients such as this patient and considered by some to be standard of care. Ordinarily, the result of the test is a pivotal factor in making a recommendation about adjuvant chemotherapy. Specifically, for those cancers that fall into the low risk category, it is generally held that chemotherapy is not worthwhile. In this instance the patient received chemotherapy, suggesting the test may not have been utilized in clinical decision-making.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-six year-old female who contracted Lyme disease is requesting authorization and coverage for intravenous antibiotic therapy.Reviewers Findings:  The reviewing physician found that the evidence provided does not demonstrate a diagnosis of Lyme disease. There is no clinical documentation of arthritis or other physical findings consistent with the diagnosis.  The reviewing physician found that the Health Plan denial should be upheld.