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

An 18-year-old male enrollee requested partial hospitalization program services for medical treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  In terms of pharmacotherapy, the patient was recently started on a serotonergic-enhancing medication for a diagnosis of depression.  The medication was prescribed at a conservative dose.  Thus, the evidence-based pharmacologic intervention had yet to approach a therapeutic trial.  While in the program, the patient was cooperative and attentive.  He was minimally participative in classes and groups.  Despite his dysphoria and affective flattening, the patient was not disruptive, agitated, psychotic, homicidal or suicidal.  He was not using substances.  There was no evidence to suggest that discontinuing partial hospital services would have resulted in an exacerbation of symptoms or clinical deterioration that would have necessitated treatment at a higher level of care.  As such, partial hospitalization program services were not medically necessary for the treatment of this patient.  Additionally, resumption of partial hospitalization program is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin-AQ NuSpin. Medical literatures report that idiopathic short stature (ISS), also called non-growth hormone-deficient short stature, is defined by a height standard deviation score (SDS) at or below -2.25 SD and associated with growth rates unlikely to permit attainment of adult height in the normal range. The authors note that the height cutoff of -2.25 SD corresponds in adults to 63 inches for North American men. In this case, the records did not document that the patients height was at or below -2.25 SD prior to initiation of growth hormone therapy. Given that the records document that the patient is likely to attain a height within the normal range for North American adult men and within two SDs of the mid-parental target height (MPTH) without further somatotropin therapy, the requested medication is not medically indicated.  Therefore, Nutropin-AQ NuSpin is not medically necessary for the 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.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 48-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her morbid obesity and hypertension.     Findings:  The physician reviewer found that it is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with a decreased over all mortality for the morbidly obese
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested cardiac computed tomography angiography for evaluation of his chest pain.  Findings:  Two physician reviewers found that cardiac computed tomography angiography is not standard accepted practice in the medical community.  If chest discomfort symptoms are of uncertain cause, then stress testing is the standard and accepted procedure of choice since it provides a functional significance to any coronary stenosis identified angiographically, it quantifies any coronary ischemia that may be present and it links the patients symptoms to provokable ischemia identified. Additionally, it assesses for causes of coronary ischemia that may be caused by conditions other than fixed obstructive epicardial coronary disease identified angiographically, such as coronary vasospasm or small vessel disease.  Likewise, if symptoms are certain to be anginal and an assessment of coronary anatomy is thought to be medically necessary, then invasive coronary angiography would be preferred over cardiac computed tomography angiography due to its improved accuracy and the ability to intervene with revascularization during the same procedure, if clinically indicated.  Current expert consensus guidelines that are endorsed by several national organizations do not consider cardiac computed tomography angiography appropriate in patients with prior coronary stenting and new symptoms suspicious of coronary ischemia.  Thus, in this patients case, cardiac computed tomography angiography performed on the date in question was not likely to be more efficacious for evaluation than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for the residential treatment services provided for treatment of the enrollees behavioral health issues.Findings: The physician reviewer found that at the time of her admission the patient did not meet medical necessity criteria for residential treatment. She was not at imminent risk of decompensation and her conditions could have been managed in a less restrictive environment. As noted by the American Academy of Child and Adolescent Psychiatry (AACAP), many programs are available to enhance social interaction and improve pragmatic speech. In addition, the patients depression and anxiety could have been managed in a less restrictive environment and the changes made to her psychotropic medications could have been made without 24-hour per day supervision.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 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

A female enrollee requested Norco for medical treatment of her chronic neck and back pain. Findings:  The physician reviewer found that there was no documentation of a significant functional deficit to support the necessity for ongoing opioid therapy. There was also no mention of a failure of non-opioid analgesics prior to the initiation of Norco. Based on the clinical information received, the requested Norco is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for gene test (CPT 81256) for elevated ferritin levels. Findings:  The physician reviewer found that the health plan has denied this test as experimental/investigational. A review of the records indicates the patient was diagnosed with elevated ferritin levels in her blood.  She underwent genetic testing to screen for hemochromatosis, which is a genetic iron disorder that causes excess iron in the body.  According to current peer-reviewed medical literature, identifying hereditary hemochromatosis (HH) is important because treatment is highly effective and safe and can prevent virtually all of the disease complications if instituted at an early stage of the disease.  HH may be suspected in individuals with unexplained fatigue, symptoms of iron overload in specific organs, unexplained liver function test abnormalities, high ferritin, or high transferrin saturation.  HFE mutation testing is appropriate in most individuals with documented iron overload as a means of determining the genetic contribution.  Patients with abnormal iron studies should be evaluated as patients with hemochromatosis, even in the absence of symptoms. Medical records explain and support that his patient has elevated ferritin, pre-diabetes, and mildly abnormal liver function tests (LFTs), and that is the reason the genetic test was obtained.  Current understanding of hemochromatosis incorporates the fact that some 30% of patients with familial occurrence of iron overload never develop symptoms of the disease. Guidelines recommend screening for hemochromatosis in patients with abnormal iron studies, liver disease or end organ damage, and this patient had these factors.  . Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical  condition. Therefore, the health plans denial is overturned. Credentials/Qualifications: Three reviewers are board certified in Hematology and Oncology 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

The patient is a 46-year-old male who first presented in outpatient care in September 2003 with an approximate two-month history of anxiety and depression, attendant with insomnia, depressed mood, loss of energy, decreased attention and concentration, and sense of panic and agitation. He noted this as secondary to several stressors including long work hours, suffering a pay cut with no cost of living increase, job promotion but uncertainty as well, refinancing his house, and his two young children being very active. The patient has been diagnosed with generalized anxiety disorder as well as major depression. He was prescribed a combination of Paxil, Trazodone, Imipramine, Lorazepam, and Celexa, the latter being the most recently added medication, as well as Klonopin. He was also seen in couples therapy in October 2003. On a follow-up visit with his psychiatrist it was noted the patient had improved mood with Celexa 20mg though he reported feeling too tired during the day. Subsequently, Klonopin was phased out. Upon the patients follow-up visit on 10/23/03, it was noted that the patient was feeling sustained improvement in mood but had periodic problems with sleep. The patient expressed an interest in taking a lower dosage of Celexa and as a result, Celexa was decreased to 10mg. By his next follow-up appointment on 11/5/03, the patient reported feeling well with 5mg of Celexa but expressed interest in discontinuing medication entirely and so plans were made for him to entirely phase out Celexa. By 12/15/03, the patient was noted to have had some relapse in his depression though he expressed ambivalence about starting a new antidepressant. Since beginning treatment, the patient has been referred to some of the psychoeducational groups offered by the Health Plan. The patient has declined to participate expressing a preference for individual weekly psychotherapy. At issue is whether individual psychotherapy sessions are medically necessary for treatment of the patients medical condition.While individual therapy is the patients preference, the submitted clinical evidence does not demonstrate that it is medically necessary. The chart notes clearly document the patients improvement with Celexa. Medicinal treatment is at least as important as therapy in the treatment of both major depression and general anxiety disorder. Furthermore, the patient and his wife have been seen in couples therapy and the patient was referred to a number of psychoeducational groups. Thus, the patient was not deprived of psychotherapeutics as a whole. The submitted evidence demonstrates that the treatment offered by the Health Plan is medically reasonable and clinically appropriate. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee has requested Tomotherapy for the treatment of his bone metastases. Findings:  The physician reviewer found that tomotherapy is a form of intensity modulated radiation therapy (IMRT) which uses helical delivery of megavoltage (MV) radiation (akin to a standard CT scanner, except that therapeutic MV radiation is delivered as opposed to kilovoltage (KV) diagnostic radiation) with a hydraulically controlled collimator to achieve modulation of the beam. IMRT (and Tomotherapy) employ inverse planning, using input dose-volume constraints, and an inverse planning algorithm which maximizes adherence to these constraints. With Tomotherapy, the treatment table on which the patient lies is moved into the bore of the machine, and as the patient is moving, the radiation is delivered in a helical manner. Tomotherapy also allows for a CT scan to be obtained prior to each treatment to ensure accurate positioning. Radiation therapy is a standard medical therapy to palliate bone metastases, and there are innumerable studies dating back decades to support this. IMRT (and thus Tomotherapy) is indicated and medically necessary in situations in which the patient previously has received radiation in order to reduce the dose delivery to the previously treated spinal cord and cauda equina. IMRT is also considered medically necessary in the treatment of oligometastases (meaning few metastases), in which the goal is prolonged disease free survival and perhaps cure in patients with few metastatic lesions. In the case of this patient, who has never received prior standard radiation therapy, and whose disease is widespread, there is no indication for IMRT, including Tomotherapy. The patients bone metastases can be appropriately treated with radiation therapy delivered using the standard approach.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravenous immune globulin (IVIG) therapy for treatment of her medical condition.  Findings:  Two physician reviewers found that clinically it would appear that this patient does not have full blown Sydenhams chorea, but rather mild tics and chorea. The literature discussed use of cephalosporins rather than penicillins as being more effective. The medical literature also suggests the use of valproic acid, haloperidol, and carbamazepine as symptomatic treatment. None of these modalities have been tried. There is some literature supporting the use of IVIG. IVIG has been reported in multiple case reports and small series to be somewhat helpful as is plasma exchange; based on the theory of molecular mimicry leading to an immune attack on the basal ganglia. Given that IVIG therapy is generally reserved for more symptomatic cases that have been refractory to standard therapy, I find that IVIG is not more likely to be effective than standard treatment.   Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in neurology 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 56-year-old female enrollee has requested a thyroid scan for evaluation of her hypothyroidism.  Findings:  The physician reviewer found that for parathyroid evaluation, a radioactive iodine scan is used to assess function of the thyroid (i.e., hot, cold, focality of overproduction of thyroid hormone). An ultrasound is used to examine the configuration of the soft tissue structures in the neck including the thyroid and parathyroids. Given that this patients laboratory testing, including TSH, T3 and free T4 are within normal limits, there is no medical reason for further evaluation of the thyroid at this time. The patients laboratory testing including calcium, PTH and TFTs are all within normal limits and the provider did not find any physical findings indicative of the need for further examination. For these reasons, the requested thyroid scan has not been demonstrated to be medically necessary for evaluation of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, breast tomosynthesis was not likely to be more beneficial for evaluation of this patient than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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:  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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Xeljanz XR. Findings:  The physician reviewer found that there is currently a lack of large randomized controlled clinical trials recommending switching from Xeljanz twice daily to once daily Xeljanz in a patient who has responded so favorably. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male with a history of head and neck pain.  He had two standard physical therapy sessions and was then prescribed an exercise program. The patients symptoms were not relieved, and his provider prescribed daily PT for approximately two weeks, without manipulation. The patient indicated he was required to go out-of-plan in order to find a provider for the prescribed therapy. He is now requesting reimbursement for therapy provided from early February 2006 through late February 2006.  The Health Plan determined the therapy was not medically necessary and denied his request.The purpose of skilled physical therapy is to provide a short-term therapeutic intervention and to devise and teach a home exercise program.  The patient participated in the therapy, received appropriate instruction and had a home program to assist in the management of his neck pain due to osteoarthritis. The additional physical therapy was maintenance in nature, and not likely to improve the patients condition/function in a more reasonable or predictable time period than with continued compliance with a home exercise program taught by a physical therapist.Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing of the left breast excision for evaluation of the enrollees recurrent left breast cancer. Findings:  Three physician reviewers found that MammaPrint is a 70 gene signature that has been shown to improve prediction of clinical outcome in women with early stage breast cancer. One research reported a study that demonstrated the validity and usefulness of MammaPrint as compared to a purely clinical evaluation of prognosis. In certain groups of patients, the test appears to be more useful than clinical features, in determining which patients should receive adjuvant chemotherapy. However, thus far MammaPrint has only been validated in early breast cancer, as an aid in making treatment decisions after the initial diagnosis of breast cancer. This is not the situation in this patient, who presents with recurrent breast cancer five years after her initial treatment. There is a paucity of data to indicate that MammaPrint is useful in this clinical situation. Given these findings, the gene testing of the left breast excision performed in this case 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 testing at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 59-year-old female enrollee has requested an additional medical opinion for treatment of her hip pain.  Findings:  The physician reviewer found that hip replacement surgery is generally an effective and successful procedure, but aseptic loosening requiring revision occurs at a rate of approximately 1% per year, with pain as the presenting symptom. Other causes of pain, such as infection, also need to be excluded, as well as less evident problems. A thorough evaluation is needed to rule out infection, aseptic loosening, stress fracture, or spinal pathology, since even the type of fixation may be implicated.  In this case, there is a lack of documentation of a thorough evaluation of the patients reports of pain, despite the presence of a normal hip x-ray. In addition, there is a report of severe degenerative disc disease, which would also warrant evaluation as a possible basis of this problem.  Under these circumstances, additional evaluation and consultation are appropriate.  All told, the requested additional medical opinion is medically indicated in this clinical situation.