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

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage of the treatment proposed by Neil Hirschenbein, MD, PhD on 9/17/16.Findings:  The physician reviewer found that the clinical evidence provided for review does not support a diagnosis of Lyme disease. The patients symptoms of fever, headache and sore throat are non-specific complaints. The provided photograph is not a typical bulls-eye lesion. The skin lesion does not appear to be classic erythema migrans that is normally associated with Lyme disease. Moreover, a normal immune system will have a positive Borrelia IgG Western Blot at six to eight weeks after infection. The IgG for this patient was negative. The submitted records do not document that this patient had the rash typical of early Lyme disease, and her reported symptoms are not suggestive of this diagnosis. 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 certification in infectious diseases 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 reimbursement and prospective authorization and coverage for long term residential psychiatric treatment in the locked facility. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is a lack of support for the medical necessity of the services at issue in this clinical setting. The patient was documented as violent, having mood lability, and hearing voices. The patient also reported thoughts of harm to himself and other people. The provider indicated that the patients symptoms remained acute and the patient was not progressing in treatment and recommended treatment at the inpatient level of care. Per the documentation provided for review, the patient has been easily agitated and antagonizing peers and staff. He has threatened harm to himself and others and has required medication for agitation. He has also attempted to elope. Applying the American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) to determine the appropriate level of service intensity for behavioral health treatment, this patient may benefit from a higher level of care at an inpatient level of care facility. The CASII utilizes dimensions including risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history provided and documentation, the patient meets CASII criteria for level 6, which correlates to secure 24-hour services with psychiatric management. This level of care is the most intensive and restrictive level of care, with active psychiatric management and daily contact with the patient. Based on the documentation provided by the staff of the residential facility, the patients clinical status, and current medical literature, this patient demonstrates that he may benefit from a higher level of care at an inpatient level of care facility. Accordingly, treatment at long term residential psychiatric treatment in the locked facility was not and is not medically necessary at this time.Final Result: The reviewer determined that 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 with sub-specialty 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: Medical Necessity
Decision: Upheld

Thirty-year old female patient with a history of nipple discharge and new asymmetric firmness in her breast is requesting authorization for a diagnostic mammogram.. The patient has a family history of lymphoma, ovarian cancer and a grandmother who had breast cancer (post menopause). The patient had a negative mammogram in 2003, as well as two ultrasounds of both breasts in 2004, and one in 2006, all of which were negative. Additionally, an ultrasound of the right breast performed in 2005 was negative. The reasons for the exams were nipple discharge, pain and palpable abnormalities.Reviewers Findings:The reviewer found that in the case of this patient, nipple discharge has been reported, but the submitted medical records do not include any notes from the patients clinician about the quality of the discharge or the physical findings. The type of nipple discharge is important in determining if further evaluation is necessary. Based upon the information provided, there is a lack of a clear clinical indication for a diagnostic mammography.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

An 18-year-old male enrollee requested Vyvanse 60 mg twice per day for medical treatment of his attention deficit hyperactivity disorder (ADHD). Findings:  Two physician reviewers found that in the medical records provided for review, there is no clear documentation explaining the duration or doses of any of the other medication that the patient has tried in the past. Further, there is no documentation to support that the patient has been treated with the maximum doses of the other medications he has tried, which have more safety data available. In addition, there is a lack of documentation of the specific symptoms or behaviors that are being addressed by the medication or the symptoms that were not controlled by his previous medication trials. Overall, there is insufficient peer-reviewed data to support Vyvanse at a dose of 120 mg per day without adequate supporting clinical data. In conclusion, the requested Vyvanse at a dose of 60 mg twice per day 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: A male enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10/325mg, one pill every six hours.  The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees pain. The submitted documentation supports the medical necessity of the requested medication quantity. Norco is an opioid analgesic recommended for pain after a trial of non-opioids have failed. Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose should be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. It also recommended that providers of opiate medication document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications.  The medical evidence supports the requested medication quantity in this patients case. Therefore, hydrocodone-acetaminophen 10/325mg, one pill every six hours 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 neurology with sub-specialty in pain 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested a hysteroscopy with polypectomy for treatment of her endometrial polyp(s).  Findings:  The physician reviewer found that based on review of the available records, the patients endometrial polyps are a medical indication for removal via hysteroscopy. This decision is independent of whether the patient plans to pursue IVF. The medical literature supports diagnostic hysteroscopy in this clinical setting. As noted by Stewart, For women with an uncertain finding on ultrasound alone or who are candidates for expectant management, we suggest sonohysterography, also referred to as saline infusion sonogram (SIS) or diagnostic hysteroscopy. The author notes that in some women, an endometrial polyp is diagnosed on an office endometrial biopsy performed to evaluate abnormal uterine bleeding. In such cases, polypectomy should still be performed if indicated (for symptom relief or to exclude malignancy), since the entire polyp may not have been removed with the endometrial biopsy. In this case, the patient has had abnormal bleeding as well as infertility. In addition, endometrial polyp(s) were identified on endometrial biopsy. Therefore, the requested hysteroscopy with polypectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services were not medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient had no post-acute withdrawals. She was not suicidal or homicidal, and she was medically and psychiatrically stable. She appeared to be engaged in her recovery. She was cognitively intact. She was not manic or psychotic. Per the discharge summary, she has had no previous treatment for substance dependence problems and there was no evidence to suggest that she would not succeed at a lower level of care. Her recovery could have continued at a lower level of care, in conjunction with additional community based Alcoholics Anonymous meetings. Thus, residential treatment center services 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Tramadol, Norco and Percocet for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  Per the medical records, non-opioid treatment options have not been exhausted.  No mention of behavior therapy has been documented or done despite much research to support its use.  In addition, all non-opioid medications have not been optimized.  All told, the requested Tramadol, Norco and Percocet are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain 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 reimbursement for thyroid gene test (Afirma gene expression classifier).Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The patients initial biopsy report came back as indeterminate atypia of undetermined significance. Afirma testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules in order to avoid needless surgeries. In this patients case, Afirma test results influenced the course of action for treatment of his thyroid nodule. Final Result: Three 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of her invasive ductal carcinoma. Findings:  The physician reviewer found that there is currently a lack of medical literature to support treatment with proton beam radiation over conventional radiation therapy techniques for breast cancer. Inadequate data is available to suggest that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated radiation therapy (IMRT) with photon techniques. In addition, consensus group guidelines from the National Comprehensive Cancer Network (NCCN) do not support the use of proton therapy in this clinical setting. In the majority of cases, IMRT or three-dimensional (3D) conformal techniques with photons is able to achieve an acceptable cardiac and lung doses in patients with left-sided breast cancer. Final Result: The reviewer determined that the requested service 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 radiation oncology 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 46-year-old female enrollee has requested for Strattera for treatment of her major depression. Findings:  The physician reviewer found that there is no objective basis for the conclusion that this patient has serotonergic syndrome. The latter represents a true, medical emergency for which inpatient medical treatment is indicated. Curiously, but significantly, the patient suffered from apparently similar muscle twitching when treated with a higher dose of Wellbutrin in combination with Strattera, and this wasnt deemed anything akin to serotonergic syndrome. Rather, it was recognized as a likely side-effect from the combination. Wellbutrin was simply decreased in dose. Finally, while adding a stimulant to an antidepressant regimen may have some value in treating depressive illness, it is unclear how the patient would have responded to a higher dose of Wellbutrin, sans Strattera.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested CyberKnife radiosurgery for the treatment of her acoustic neuroma. Findings:  The physician reviewer found that the three major treatment options for acoustic neuromas are observation, surgery, and radiation therapy. Observation is usually reserved for patients whose symptoms and/or tumor size are stable or progressing only slowly. Stereotactic radiosurgery (SRS) is a technique that utilizes multiple convergent beams to deliver a single high dose of radiation to a radiographically discrete treatment volume, thereby minimizing injury to adjacent structures. This can be accomplished with either the gamma knife or a linear accelerator. Radiosurgery is a viable treatment option for selected patients with smaller tumors (less than 3 cm) or for enlarging tumors in patients who are not candidates for surgery. One of the largest experiences with SRS comes from 829 patients with vestibular schwannoma studied by Lunsford and colleagues. The overall tumor control rate was 97% at 10 years. Given this particular patients increase in symptoms and growth in tumor size, treatment rather than continued observation is now medically indicated and necessary. SRS is an appropriate treatment option for this patient and likely to yield good results. However, the types and delivery methods of SRS, (i.e. gamma knife, Novalis and CyberKnife) have not yet been directly compared in randomized, blinded studies, so the superiority of one over the other for the treatment of acoustic neuromas cannot be established at this time. Thus, I have determined that this patient should be approved for SRS, but without any clinical support suggesting that CyberKnife is superior to gamma knife or Novalis, the CyberKnife portion of the patients request should be denied.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a colonoscopy. The most recent joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that the interval for repeat screening colonoscopy depends on the findings at the baseline colonoscopy and subsequent colonoscopies. The guidelines state that individuals with 5 to 10 adenomas, an adenoma that is 10 mm or greater in size, or an adenoma with villous component or high-grade dysplasia, should undergo surveillance three years after the prior colonoscopy, which would warrant colonoscopy in this case approximately one year from now. In this case, the patient has a 10 mm adenoma to meet the recommendation for a repeat colonoscopy in three years. Only patients with more than 10 adenomas, or piecemeal resection of an adenoma or sessile serrated polyp, are recommended to have a repeat colonoscopy at one year or less. Under these circumstances, the requested colonoscopy is not medically necessary at this time. Accordingly, the requested colonoscopy is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for 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 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

The patient is a 56-year-old right-handed woman who underwent right wrist surgery in March 2005. She developed an infection, which led to persistent swelling and stiffness in the fingers and wrist. She was unable to participate in therapy due to the ongoing infection. A request has been made for authorization for a continuous passive motion (CPM) machine. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be overturned. The patient is right-hand dominant with significant stiffness and edema postoperatively. A CPM machine would be useful along with therapy to help the patient regain strength and motion. Use of a CPM machine for a three-week period is medically appropriate and indicated based upon the patients current condition. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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.