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 fentanyl patch 12 mcg/1 hour, one patch every 72 hours, quantity of 10 patches for treatment of the enrollees neurofibromatosis and multifocal pain. Findings:  The physician reviewer found that review of the submitted documentation supports the medical necessity for the requested medication. Opioid medication may be considered as part of the standard of care when treating patients with chronic nonmalignant pain. Concern for opioid misuse can result in undertreatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. In support of prescribing opioids, controlled trials have shown a modest effect in terms of analgesia with opioids. Judicious prescribing and monitoring remains a viable option for selected patients. In this case, the patient presents with ongoing chronic nonmalignant pain and extended release morphine had been ineffective. There is no evidence of a violation of an opioid agreement or contract or refusal to participate in urine drug screening or completion of readily available tools used in the assessment of pain and function. There is no evidence of a treatment plan to provide another medication in the same class at an equivalent MED. For the reasons provided, the request for fentanyl patch 12 mcg/1 hour, one patch every 72 hours, quantity of 10 patches has been established as medically necessary for the treatment of the patients medical condition. 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 physical medicine and rehabilitation 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: Medical Necessity
Decision: Overturned

A 65-year-old female has requested acupuncture (voice acupuncture) for treatment of her spasmodic dysphonia.  Findings:  The physician reviewer found that  based on review of the available records, this patient presents with a condition for which she underwent acupuncture care in the past with significant benefit. Botox injections are a more aggressive type of treatment, with more possible complications than the additional acupuncture requested by the patient. In one study, acupuncture was compared to Botox therapy, with demonstrated equivalent benefits. As this patient has experienced benefits with previous acupuncture treatment for her diagnosis of adductor spasmodic dysphonia, and the peer-reviewed medical literature supports its use, the requested acupuncture care is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laboratory testing to measure serum levels of Remicade (infliximab) for treatment of her medical condition.  Findings:  Three physician reviewers found that the use of measure serum levels of infliximab to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). A systematic review reported that future prospective controlled studies are needed, especially considering anti-tumor necrosis factor (TNF) levels are influenced by several variables that can fluctuate over time and among individuals (Yarur, et al). Based on the clinical literature, the requested services remain controversial and have not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in gastroenterology 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 reimbursement and prospective authorization and coverage for inpatient psychiatric hospitalization. The patients characterological organization, affective illness and anxiety burden is complicated by a poorly defined self-concept, the confluence of which contributes to a recurrent and refractory symptom complex.  Currently, the patient is symptomatic and in need of specialty care. Based on her longitudinal history and psychosocial stressors, coupled with the symptom complex that includes need for assistance with activities of daily living, outpatient-based services would be inadequate at this time. However, the patient is not suffering from an acute psychiatric syndrome.  She is not suicidal, and she is not psychotic. She is neither disorganized in thought nor agitated in behavior. She is sleeping well and has good impulse control. Per the medical records, treatment at the residential level of care was and is medically appropriate. Therefore, inpatient psychiatric hospitalization was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee, with painful varicose veins of the labial area, has requested authorization for sclerotherapy. Findings:  Three physician reviewers found that Sclerotherapy has higher primary failure and recurrence rates than other available treatment modalities. As in this instance, when the goal of treatment is saphenous closure,  radiofrequency ablation or endovenous laser therapy, or even stripping, have consistently greater efficacy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 23-year-old female with approximately a two-year history of bulimia nervosa with episodes of binging and purging up to three times per day. Each binge lasted one to two hours with the patient sometimes eating to the point of physical pain. The patient also noted having grown increasingly depressed in the seven months prior to admission following the breakup of a relationship with her boyfriend, with subsequent lethargy, increasing social isolation, and irritability. This was compounded by her use of amphetamine, particularly flagrant in the three to four months prior to her inpatient admission in October 2002. Because of the perceived cycle of the patients binging and purging as well as the use of amphetamine, she was thought to be in need of inpatient psychiatric treatment.Review of the records provided indicates the patient was admitted with a body weight of 123 pounds, with her ideal weight being 120 pounds plus/minus 10%. She was mostly maintained on a regimen of Prozac 60 mg per day with which she had been treated in prior weeks. The remainder of the notes indicate the patient complied entirely with meal plans and maintained her weight with absolutely no episodes of binging or purging. She was also able to tolerate some therapeutic passes without any resumption in binging or purging. The prescribed dosage of Prozac was eventually lowered to 40 mg. The patient did have one instance of lightly cutting on herself, having done so due to a perceived lack of emotional outlet, what with no longer binging or purging. This sort of behavior remitted with staff redirection.Overall, despite the patients bulimia nervosa and amphetamine abuse, her presentation did not seem to reflect any particularly acute or urgent need for inpatient treatment. Specifically, her weight was entirely normal, she was not acutely depressed, and she was fully and immediately compliant with the therapeutic program with not a single episode of binging or purging. None of the submitted notes reflect the patient being notably depressed. In fact, the notes actually point to how euthymic she appeared. Hence, while treatment was indicated for this patient, it could well have been first approached from a partial hospitalization or intensive outpatient perspective.  Therefore, I have determined that the services at issue were 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: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees cutaneous melanoma.  Findings:  The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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: Physician reviewer number one is board certified in dermatology 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.Physician reviewer number two is board certified in dermatology 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.Physician reviewer number three is board certified in dermatology 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: The enrollee requested authorization and coverage for insertion of a spinal stabilization device, Coflex. The peer-reviewed literature has several studies that support the use of interspinous fixation as an adjunct to decompression in patients with lumbar spinal stenosis and Grade I spondylolisthesis. Davis and colleagues demonstrated in a high quality randomized multicenter study that low-grade spondylolisthesis was effectively stabilized by Coflex. In this case, the patient has evidence of spinal stenosis at the L4-5 level with Grade I spondylolisthesis. Therefore, the insertion of a spinal stabilization device, Coflex, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the insertion of a spinal stabilization device, Coflex, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested device 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Queen Kings Down 4000 and Temp Curve Pillow for treatment of the enrollees back and neck pain. Findings:  The physician reviewer found that the patient presents with chronic neck and back pain. The patient has completed a course of physical therapy and continues to have chronic pain interfering with the ability to work. The patient has comorbid medical and psychiatric conditions that limit medication options. Thus, the use of a neck support pillow while sleeping in conjunction with daily exercise in the treatment of chronic neck pain is clinically indicated. The patient has completed physical therapy and the requested pillow as an adjunctive treatment with her home exercise program has been established as medically necessary for the treatment of the patients medical condition. In terms of the request for Queen Kings Down 4000, there is a lack of high-quality studies to support purchase of any type of specialized mattress or bedding as a treatment for low back pain. There is no deformity that would indicate a need for positioning that would require a special bed. For these reasons, the requested Queen Kings Down 4000 mattress is not considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment is 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 physical medicine and rehabilitation 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Accutane 40 mg. The U.S. Food and Drug Administration (FDA) approves the use of Accutane (generic name isotretinoin) for the treatment of severe acne. A study describes isotretinoin as the most effective treatment for acne. In this case, the patient has a diagnosis of acne vulgaris with scarring, indicating a severe condition. The records documented the patient had been treated with isotretinoin with good response, and the provider has recommended continued therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Accutane 40 mg is medically necessary for the treatment of this patient.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 dermatology 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 parent of a 14-year-old female enrollee has requested  for residential level substance abuse treatment or intensive outpatient program substance abuse treatment for treatment of the enrollees alcohol dependence, cannabis dependence, and amphetamine dependence. Findings:  The physician reviewer found that the patient has had repeated access to both mental health and substance abuse residential, inpatient and outpatient treatment.The patient did not demonstrate improvement.The medical records do not demonstrate adherence to treatments or motivation for recovery.  Thus, there is no reasonable expectation that, if offered again, these services will improve the patients presenting problems.  Treatment for individuals with substance abuse disorders have evolved over the years from a largely inpatient to an outpatient setting.  All told, the requested residential level substance abuse treatment is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ribapak and Technivie for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Ribapak and Technivie are medically indicated 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.  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

The parent of a seven-year-old female has requested a foot brace insert consisting of removable, molded to patient model, longitudinal/metatarsal support (CPT code L3020) for treatment of her congenital pes planus.  Findings:  The physician reviewer found that it is not medically necessary for this patient to have custom orthotics prescribed as first-line treatment. It is a time of rapid growth of the patient. It is reasonable that she receive a trial of non-custom fabricated orthotics or a carefully selected recreational sneaker with longitudinal arch support and metatarsal pad. The patient should also have a careful evaluation to rule out a non-flexible flatfoot. There should be documentation of whether the patient has heel cord tightness. Once the primary orthopedic conditions are ruled out, then a simple soft orthotic is indicated. However, the requested custom molded orthotic is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested speech therapy for treatment of the enrollees stated condition of a speech delay.  Findings:  The physician reviewer found that this patient has an identified articulation disorder of speech with a mild receptive/expressive delay.  Speech therapy is indicated with any delay greater than 25% (Feldman & Messick and Law, et al.). Extensive review of the literature including meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children with articulation disorders typically have mild-to-moderate deficits in speech, and most of their speech may be intelligible to unfamiliar listeners despite the errors. The goal of articulation therapy is for improvements in functional communication. Speech therapy is particularly useful in helping affected children to identify and practice the mature patterns of speech. Children with speech disorders often experience embarrassment and poor self-esteem. Therapy is designed to reduce the negative psychological consequences of the disorder and direct remediation (Feldman & Messick). Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). This patient continues to display expressive and receptive language impairment with a significant articulation disorder.  Therefore, speech therapy is medically necessary for this patient.