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

A 43-year-old female enrollee has requested reimbursement for substance abuse residential treatment center services provided at Passages Treatment Center for almost one month.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Modern psychiatric practice aims to provide care in the least restrictive setting that is likely to effectively address the issues which are causing functional impairment.  Providers rely on practice guidelines, peer-reviewed literature, and placement criteria when determining the appropriate level of care.  Per the American Psychiatric Association, residential treatment is indicated for patients who do not meet the criteria for hospitalization but whose lives focus predominantly on substance use.  The American Psychiatric Association notes that residential treatment may be indicated for patients who lack substance-free social supports to maintain abstinence in an outpatient setting.  In this patients case, her alcohol use dominated social and family dynamics.  She lacked adequate social supports to facilitate recovery.  Additionally, she had failed a less restrictive setting prior to the disputed services.  The current medical evidence support substance abuse residential treatment center services in this clinical setting.  All told, the substance abuse residential treatment center services provided were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees major depressive disorder.    Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, this patients treatment with TMS therapy was likely be more beneficial for treatment of her medical condition than any available modality and should therefore be covered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Cosentyx.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees severe hidradenitis suppurativa (HS).There is evidence in the medical literature that supports treatment with Cosentyx may be effective for treatment of HS. According to a study, after 12 weeks of treatment with Cosentyx, the number of lesions reported by one patient within the period of the last four weeks was reduced from 23 to seven. In this case, the patient presents with severely recalcitrant HS, which has been unresponsive to treatment with combination oral antibiotics, topical antibiotics, isotretinoin, Anakinra, and Humira. In addition, the patient was treated with Humira for 10 months and developed neurological side effects requiring discontinuation of the medication. As there are a lack of other alternatives available, the request for Cosentyx has been established as medically necessary for treatment of the patients chronic HS. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the patient is a female who had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The patient has several additional risk factors for developing cancer, including a personal history of breast cancer. The patient has requested reimbursement for the digital breast tomosynthesis performed.  The Health Plan has denied the reimbursement. Per the Health Plan, digital breast tomosynthesis was investigational/experimental for evaluation of this patient. The digital breast tomosynthesis performed was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: 2/3 of the reviewers have determined that the service at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Testopel pellets. The Endocrine Society and American Urological Association (AUA) have published guidelines to direct treatment of hypogonadism. According to the current guidelines, patients with signs and symptoms of testosterone deficiency plus a consistently low serum total testosterone and/or free testosterone, less than 300 ng/dl  for patients under 70 years of age. Documentation of low fasting morning serum testosterone on at least two occasions is required. Treatment for hypogonadism addresses adult patients who are hypogonadal as evidenced by suggestive clinical symptoms such as decreased libido, low bone mineral density, and small testes, as well as low morning serum testosterone levels. The American Urological Association (AUA) guidelines for the treatment of hypogonadism describes the different testosterone preparation including gels, transdermal, intranasal, buccal agents, intramuscular injections and subcutaneous pellets. About 70-80% of patients achieved a total testosterone concentration within the physiological range at steady state with all these agents. Overall, the data suggests equivalence among the different forms of testosterone preparations. In this case, the patient has lab results showing a consistently low morning testosterone below 300 ng/dl. The patient has undergone adequate work-up for primary or secondary hypogonadism with measurements of luteinizing hormone (LH) and follicle stimulating hormone (FSH). The records support a diagnosis of hypogonadism per Endocrine Society and AUA guidelines. The patient had also tried and failed testosterone cypionate intramuscular injections. Testosterone implants have improved the patients testosterone level, energy and libido. For these reasons, the Testopel pellets were and are 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 medication at issue was and 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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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: Upheld

A 57-year-old female enrollee has requested a portable ultrasonic nebulizer (and related accessories and supplies) for the treatment of her asthma. Findings:  The physician reviewer found that the submitted clinical and hospital records confirm the diagnosis of asthma with a history of hospitalizations and thoracotomy. The records provided indicate the patient has been using an albuterol sulfate nebulization solution and Pulmicort Flexhaler inhaler. The submitted records do not however demonstrate the medical necessity of the requested ultrasonic battery-driven nebulizer. The generally accepted medical practice is to prescribe a standard nebulizer. The records indicate that the patient already possesses a nebulizer. If replacement is necessary, a standard nebulizer is warranted for her condition. The patient states that she has managed her condition with use of an ultrasonic nebulizer for 10 years and failed earlier attempts with compressor type nebulizers. Ultrasonic nebulizers are used primarily to deliver drugs to the lower airway. This patient has asthma, which is a disease of the upper and mid airways; thus, the ultrasonic mode of therapy is not medically necessary for this patients diagnosis. Standard nebulizers are the most commonly prescribed for patients with asthma since they are considered the most reliable device for that purpose. They are impaction jet nebulizing devices which are capable of delivering the appropriate medications, as compared to ultrasonic vibrating crystal nebulizing devices, which are designed to deliver smaller particle medication deep into the lungs.
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 the guidelines, treatment-naive genotype 1 patients should be treated. This guideline recommendation is based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The physician reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested  coverage for speech therapy at a frequency of one and a half hours per session for two sessions per week for treatment of  his speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in his receptive language skills of approximately 33% and of greater than 50% in expressive language skills.  Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Extensive review of the literature, including the 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 who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment and found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. In sum, speech therapy at the requested frequency of one and a half hours per session for two sessions per week is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 24-year-old male with a three-year history of polysubstance abuse including cocaine, alcohol and marijuana who was admitted to inpatient treatment in May 2006 following a relapse. He was involved in outpatient treatment for substance abuse for approximately five months prior to inpatient admission, and had not used any substances from November until mid March when he and some friends used alcohol and cocaine at a party. In May 2006 the patient again used alcohol and was expelled from the outpatient program. On the recommendation of his outpatient provider, he was referred for inpatient treatment. His initial diagnoses included major depression, moderate, recurrent, personality disorder, and alcohol dependence.During his inpatient course of treatment, the patient was described as motivated for treatment, cooperative and an active participant in the various therapies and 12-step meetings. He presented as euthymic with congruent affect, linear thought processes, good insight and judgment and unimpaired perceptual and thought content. He was also noted to be able to contract for safety.  The patient continued treatment with Lamictal 250mg and Celexa 40mg without adjustment of his previous outpatient dosages; his Zyprexa was discontinued.  He was not described as significantly depressed or suicidal at any point during his inpatient stay.The patients request for reimbursement for acute inpatient substance abuse rehabilitation services provided from May 2006 through May 2006 was denied by the Health Plan citing a lack of medical necessity. The basis for the patients inpatient referral is not clear; relapses often occur in this setting and do not equate to a need for inpatient treatment. The patient did not require detoxification as his use of alcohol and cocaine was highly variable, he was a willing participant in his treatment, and his depression was quiescent. It is obviously within the purview of his former outpatient program to suspend him for noncompliance with their rules, but an alternative outpatient program should have been identified prior to May 2006. All told, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old male with chronic back pain and a history of opioid dependence. He has requested authorization and coverage for Subutex for pain control. The Health Plan has denied the patients request indicating the requested medication is not medically necessary for treatment of the patients condition.Review of the submitted clinical records documents a significant pain condition requiring treatment. There is documented evidence Subutex has been beneficial for this patient. Based upon the patients history and documented response to Subutex, continued use of Subutex is medically reasonable and appropriate and should be authorized. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested natural desiccated thyroid hormone replacement for treatment of her Hashimoto thyroiditis.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for natural desiccated thyroid hormone replacement has been established. The documentation submitted for review demonstrates that the patient has had improvement in her symptoms when switched to Armour Thyroid. The patient reports symptoms of headaches, nausea, gas and bloating and diarrhea and joint aches from levothyroxine. In this case, Armour Thyroid is likely to be safe as long as the levels are monitored closely. Given that the patient reports side effects from the levothyroxine it is reasonable and medically necessary for the requested medication. According to Ross Often, patients who are doing well symptomatically on a combination preparation (eg, Armour Thyroid) refuse to be switched to T4. As long as their thyroid function tests are normal and are monitored periodically, it is probably safe for them to continue to take the thyroid preparation they prefer. For the reasons provided, the patients request for natural desiccated thyroid hormone replacement is medically necessary.   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 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: Upheld

The patient is a 19-year-old male who was on probation for assault and was admitted to a 30-day residential treatment program for substance abuse.  He attended two previous treatment programs prior to becoming an adult and has been arrested three times.  The patient was adopted and never knew his biological parents.  He believes they were both  drug addicts. The notes from the residential treatment facility support a supposition that the patient was participating primarily because of the legal ramifications of not doing so.  He did not appear motivated or actively engaged in the treatment program.  The patient requested reimbursement for residential treatment services provided from February 2006 through March 2006.  The Health Plan denied his request based upon a determination that the services were not medically necessary.The patient had no signs of withdrawal and did not appear to be at risk for withdrawal when he was admitted to the residential treatment facility.  Although there were concerns that being with friends or in the school environment might make recovery more difficult, there were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. The patients home environment was supportive and conducive to recovery.  A partial hospitalization program (PHP) for substance abuse rehabilitation would have been appropriate. In PHP the patient would have participated in a structured therapeutic program and his drug use would have been monitored with urine drug screens. The patients admission to residential treatment appears to have been motivated by his legal status to a significant extent.  At this age, the patients conduct and behavioral problems are not best approached by psychiatry and the strict behavioral controls set by outside agencies are likely to be more effective. Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The mother or a five-year-old male enrollee has requested for partial hospitalization program (PHP) services for treatment of the enrollees attention deficit/hyperactivity (ADHD) and anxiety disorders. Findings:  The physician reviewer found that clearly this is a seriously troubled child in need of intensive psychiatric care. He was unable to function in a pre-school program despite many months of outpatient care and a variety of psychotropic medications. His initial response to the PHP was good. A diagnosis and treatment plan is clearly a part of the clinical record provided for review. The fact that he had improved in no way indicates that the child had integrated the behavioral controls provided to him in the treatment setting. His rapid regression and subsequent need for readmission are not surprising.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested for an interferential unit/TENS unit for treatment of his chronic shoulder pain. Findings:  The physician reviewer found that there is a lack of published, high-grade, randomized, controlled trials that have demonstrated the efficacy of interferential stimulation devices in musculoskeletal conditions or pain syndromes over placebo controls or basic conventional care consisting of analgesics, self-applied thermal modalities and a self-directed exercise program.  All told, the requested interferential unit/TENS unit is not medically necessary for the treatment of this patient.