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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that as per the combined American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA) guidelines, treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies due to comorbid conditions. This recommendation was given a rating of Class I, Level A. This recommendation was formulated based on the recognized benefits associated with successful HCV treatment. Clinicians should treat HCV infected patients with antiviral therapy preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of sustained viral response. In sum, the requested authorization and coverage of Harvoni is medically necessary in treatment of the patients hepatitis C virus. Final Result: The reviewer determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested a follow-up colonoscopy for evaluation of his history of an adenomatous colon polyp.  Findings:  The physician reviewer found that according to the most recent American College of Gastroenterology guidelines for colorectal screening, a follow-up colonoscopy is not medically indicated at this time.  Based upon these guidelines, a follow-up colonoscopy is medically indicated five years after the prior colonoscopy.  All told, the requested follow-up colonoscopy is not medically indicated for the evaluation of this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested psychiatric residential treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that while the patients issues were legitimate problems, there appears to be no documentation to support her being so compromised in function to warrant inpatient treatment of any kind. Family therapy was a necessary component of treatment, but this could have been approached on an outpatient basis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested Zepatier for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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. After failure of NS5A inhibitors such as Harvoni, AASLD/IDSA guidelines state that patients who are high priority for treatment should undergo testing for resistance-associated variants before re-treatment. No NS5A or NS3 inhibitor resistance testing results have been provided in this case. If there is no NS5A resistance, Zepatier is not recommended.  When resistance to NS5A inhibitors is present, the AASLD/IDSA guidelines do not recommend use of Zepatier therapy unless there is also NS3 resistance.  If both types of resistance are present, Zepatier should not be used alone. Alternative therapies are recommended in most cases. Based on the information provided, the available medical literature does not support the use of Zepatier in this case.  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 physician 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 patient is a 16-year-old female with an apparent history of depression evidenced by acting out aberrant behaviors, substance abuse, poor attendance and grades in school, and three psychiatric hospitalizations. Although the duration of treatment is unknown, the patient has been treated with Depakote and Lexapro. The patients biological mother is reported to have serious substance abuse issues and is unavailable to the patient who was raised by various family members and then adopted by an aunt and uncle. The patient has been receiving intensive outpatient therapy; however, inadequate treatment records have been submitted for review. The Health Plan has denied authorization for continued intensive outpatient therapy.Although there is some initial clinical information and a treatment plan available for review, there are no clinical records documenting the services the patient received and the patients progress. Although it is apparent the patient required some therapeutic intervention, there is no documentation supporting the need for intensive outpatient therapy. A review of the information submitted indicates the Health Plan made a number of attempts to obtain further clinical information from the patients providers without success. Based upon the information submitted, there is no documentation supporting the need for the requested services. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested psychiatric residential treatment services for treatment of his behavioral health problems.  Findings:  The physician reviewer found that the patient came to the program with genetic loading for depression and gifted intellectual functioning. His symptoms of depression were significant, if not profound.  However, he denied suicidal ideation, homicidal ideation and had no evidence of a thought disorder clinically or by psychological testing. While the patient did benefit from his residential treatment stay, his condition could have been treated with more frequent and appropriate office-based medication management or psychotherapy visits as of the date in question. The interventions the patient received while in residential treatment could have been obtained in the community including psychological testing, individual therapy twice a week and family therapy. All told, the submitted evidence demonstrates that the patient would have been able to be safely treated at a lower level of care as of the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested total hip replacement for treatment of her avascular necrosis of the left hip.  Findings:  The physician reviewer found that based on review of the available records, this patient is obese. Her treating provider has deferred proceeding with the requested procedure as her weight could cause significant problems. In a study by Chee and colleagues, the authors found that massive obesity has an adverse effect on patients undergoing total hip replacement. In a study by Haverkamp and colleagues, the authors noted that obesity appears to have a negative influence on the outcome of total hip replacement. The records indicate that this patient is 41 years of age and weighs approximately 300 pounds. Therefore, this patients weight is likely to cause problems with the requested total hip arthroplasty. Consistent with the current medical literature, total hip arthroplasty is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested for Botox injections for treatment of her headaches and cervicalgia.   Findings:  Three physician reviewers found that Botulinum toxin (Botox) is focally-acting protein that inhibits the release of the neurotransmitter acetycholine from presynaptic nerve endings. Recent evidence has shown that Botox also blocks the neuronal release of nociceptive medicators. Freitag and colleagues found that Botox may be an effective treatment in patients with chronic migraine without medication overuse. Mathew and colleagues as well as Silberstein and colleagues also found that the use of Botox as prophylactic therapy for the treatment of chronic headache is effective.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male has requested spine nerve treatment consisting of radiofrequency neurolysis on the right side for treatment of his low back pain.   Findings:  Three physician reviewers found that this case involves a patient with a longstanding history of low back pain and who also underwent multiple surgical interventions. The provider has diagnosed him with post surgery syndrome, lumbar degenerative disc disease and lumbar facet joint arthropathy. The provider also performed facet joint nerve blocks on two occasions on the left side at L2, 3 and 4 levels. There was no L5 dorsal ramus block based on the available notes. Further, the first block involved injection of 1 mL of 0.25% bupivacaine at each level, whereas it appears that the second block involved injection of 2 mL with 0.25% bupivacaine and 40 mg of Kenalog with 1 cc each at each level. The provider has recommended right side nerve blocks consisting of neurolysis.  The records do not demonstrate that the patient has already undergone appropriate diagnostic medial branch injections on the right side, and if so, the patients response. Based on the available notes, it appears that a potential diagnostic nerve block was performed on the right side. However, the patient reportedly received 240mg of Kenalog, which is a high dose that is not clinically recommended. The medical literature suggests that diagnostic blocks are extremely important and they must be performed with very low volumes, preferably around 0.5 or 0.6 mL, or less (Manchikanti, et al). They should be controlled diagnostic blocks utilizing either controlled comparative local anesthetic blocks or placebo-control. Moreover, there was no quantification in the records of the patients relief. A positive block is defined as a predetermined criteria, either 50% or 80% relief, and with ability to perform previously painful movements. There was no such documentation included in the patients records provided for review. The response with radiofrequency neurotomy in patients who have not undergone diagnostic blocks was in the placebo range and reported to be less than 35% patients reporting improvement at three-month follow-up (Cohen, et al). Based on the available records and current literature, there is no indication for the requested right sided radiofrequency neurotomy without controlled diagnostic blocks.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for additional non-emergency transportation. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The patients documented history and examination findings do not indicate that she has any impairments that would preclude the regular use of public or private transportation to go to her medical appointments.  Increased physical activity, moreover, is generally appropriate and recommended for conditions such as obesity, hypertension, diabetes, fibromyalgia, and for general musculoskeletal health.  In sum, additional non-emergency transportation is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck (CPT code C72141). The records provided for review document that this patient has neck pain but no neurological deficits. There is no history of trauma, malignancy or infection. Plain film x-ray results were not provided for review. While the patient has tried ice and analgesic medications, there is no record of any attempt of conservative management including physical therapy. According to the American College of Radiology (ACR) and National Imaging Associates (NIA) guidelines, a magnetic resonance imaging (MRI) of the cervical spine is not indicated in this clinical setting absent a six-week trial of physical therapy. The records do not document any infection, trauma or concerning symptoms to support an indication for an MRI of the cervical spine. Therefore, the requested MRI of the cervical spine is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested reimbursement and prospective authorization and coverage for intensive outpatient therapy (IOP) for treatment of her behavioral health condition.  Findings: The reviewer found there is sufficient support in the documentation for the services at issue in this clinical setting. To objectively determine the appropriate level of care for the patient, this case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. According to CALOCUS criteria, her risk of harm is considered significant with a score of 3.  Recent gains in her functionality have been achieved while participating in structured settings. The patient has trouble with social interactions due to her emotional dysregulation. Her functional status is moderate with a score of 3. The patient has a comorbidity of bipolar disorder and substance abuse.  Accordingly, her comorbidity score is a 3 with significant comorbidity. As to this patients environmental stress, it is scored as mildly stressful with a score of 2. The patients parents are supportive. There is some stress and discomfort due to expectations for school and home performance by the patient. As noted in the documentation, this patients parents are supportive and so her environmental support is scored a 2. The records indicate that the patient has a limited ability to deal with stressors. She copes with stressors by cutting and still struggles with emotional dysregulation.  Recovery has been maintained for moderate periods of time. As to her resiliency and treatment, her score is a 3 with equivocal resiliency and response to treatment. It appears that the patient is cooperative and compliant with treatment recommendations from her medical providers. She is able to develop a positive relationship with care providers. As such, her acceptance and engagement would be constructive with a score of 2. This patient according to the CALOCUS system has a composite score of 18. Therefore, the patient has met and does meet criteria for IOP services.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine 30 mg four times per day. Findings:  The physician reviewer found that morphine is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Guidelines provide specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. Guidelines also recommend 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. It is not clear in this patients documentation, that the use of the prescribed opioid medication has decreased the level of pain the patient reported from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription for morphine. There is also significant risk of comorbidity when combining a benzodiazepam with an opioid, particularly in a patient with a condition of respiratory compromise such as COPD.  For these reasons, the request for morphine 30 mg four times per day is not medically necessary for treatment of this patients medical condition. 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 neurology 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: Upheld

The patient has requested authorization and coverage for physical and occupational therapy in a skilled nursing facility (SNF). The records provided for review do not demonstrate that this patient requires skilled nursing level of care services. The documentation does not reveal complex wound care, new enteral feeding or other skilled nursing needs that requires a SNF admission with services performed only by a skilled nurse within a SNF. The patient does not require continued skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide reasonable treatment at a SNF level. The patient has been receiving therapy for her condition. The documentation does not support that she needs a skilled therapist to supervise or perform this therapy at a SNF level. The patient may benefit from additional physical, occupational and speech therapy but the documentation does not support that she needs inpatient care in a SNF with a skilled professional therapist on a daily basis. All told, the requested physical and occupational therapy in a SNF is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

The parent of a seven-year-old male enrollee requested one hour of speech therapy at the frequency of 1-2 times per week for medical treatment of the enrollees severe receptive and expressive language delays.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. Language deficits are one of the core aspects of autism and speech therapy provides professional help and guidance on communication development for individuals with autism (Myers, et al). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Goldstein). Based on the medical literature cited above and the documentation submitted for review, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old male enrollee has requested for Xyrem for treatment of his excessive daytime sleepiness. Findings:  The physician reviewer found that the data on Xyrem suggests that even in patients with mild-moderate sleep apnea, there was no respiratory suppression observed (see George, et al. and Wang, et al.). Xyrem has been used for other diagnoses and with patients such as this patient who were stages 3-4 sleep deprived with great benefit (see Scharf, et al. and Ondo, et al.).
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested authorization and coverage for bariatric surgery consultation and surgery for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that based on review of the available records, this patient is morbidly obese with a BMI of 39 with diagnosed diabetes and hypertension. She meets all standard generally accepted criteria for bariatric surgery, including the National Institutes of Health (NIH) consensus guidelines. Specifically, the patient has documented morbid obesity with a BMI of 39. In addition, the patient has evidence of co-morbid conditions with diabetes and hypertension. Further, the patient has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, medical or metabolic barriers to surgery. Finally, the patient has failed dietary efforts in the past consisting of both supervised and unsupervised weight loss attempts that is documented in the records provided for review. All told, the patient meets the NIH consensus guidelines for bariatric surgery at this time. Therefore, the requested consultation and bariatric surgery are supported as medically necessary for treatment of this patients medical condition.