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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity for the services at issue in this clinical setting. By the discharge date, he had no post acute withdrawal symptoms. There was no evidence of suicidal or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The progress notes stated that he was engaged and participating well.  He was motivated.  His mood was sad and anxious, and his affect was flat.  On the date of service in question, he was cooperative, and his affect was reactive and mood congruent.  The patients thoughts were linear and goal directed. He had identified a sponsor. He was using mindfulness and relaxation techniques.  On the date of service in question, he reported ongoing memory problems, but denied cravings. He was motivated and appeared to be working the program. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The progress notes documented that he was cooperative and participating in his treatment plan.  There were no new problems. There was no evidence that returning him to his environment would result in decompensation or relapse. He had extensive prior experience with AA meetings, and had obtained a sponsor. Based on the submitted records, this patient no longer required the structure of residential level of care by the date of service in question.  He could have stepped down to an ambulatory level of care, such as intensive outpatient program. All told, the RTC services received during the dates of service in question were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the heart computed tomography (CT) scan performed for evaluation of the enrollees history of chest pain, dizziness and seizure. Findings:  Two physician reviewers found that this patient presents with multiple medical conditions, some coronary risk and chest/shoulder pain that was not further characterized at the clinic visit. In this circumstance, the records provided for review do not support an indication for a cardiac CT scan. There is no documentation to suggest the patients chest discomfort is suspicious for angina, and no other symptoms or objective findings are concerning for coronary ischemia. When chest discomfort is suspicious for coronary ischemia, then the guidelines recommend stress testing. Coronary CT scanning provides an assessment of coronary anatomy only and does not assess the functional significance of any stenosis identified. The current guidelines endorsed by several national organizations do not consider coronary CT scanning appropriate based on the documentation provided. For these reasons, the heart CT scan performed 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 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

The parent of a four-year-old male enrollee has requested speech therapy and an apraxia test for the treatment of the enrollees speech disorders. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. This may lead to overall academic underachievement and, in some cases, lower IQ scores that may persist into young adulthood (Nelson and colleagues). Thus, the long-term consequences of speech and language may be substantial. Law and colleagues concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. While unstructured spontaneous speech or recitation may be possible in some cases, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensori-motor processing at the central level. This type of impairment is frequently seen after stroke or with congenital disorders, but may also be seen in otherwise normally developing children. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, communication at all levels may ultimately be impaired (Lewis and colleagues). In summary, the literature supports the efficacy and medical necessity of speech and language therapy for verbal apraxia as well as phonological disorders. Intensive speech therapy and associated apraxia testing is therefore medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollees parent requested authorization and coverage for genetic test, Coagulation Factor V gene analysis for Leiden Variant. The enrollee has irregular menstrual cycles, which are becoming heavier and she can skip up to one month. She also has cramps but medication has not helped. She has a headache and dizziness occurring every two weeks. The pediatrician noted a family history of Factor V Leiden mutation and recommended blood work to check for Factor V Leiden mutation in this enrollee. If negative, a prescription for birth control would be provided to the enrollee. The detection of genetic defects provides information that is helpful to determine the risks and benefits of using estrogen-progestin contraceptives. However, the medical literature does not recommend screening women who are taking oral contraceptives or estrogen replacement for inherited thrombophilia, unless a first-degree relative has inherited thrombophilia and clinical thromboembolic disease. There is insufficient evidence in the record the enrollee fulfills these criteria. Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in obstetrics and gynecology 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: The parent of a two-year-old female enrollee has requested reimbursement for the services provided by the Early Childhood Treatment Center. Based on the available documentation, the services provided by the Early Childhood Treatment Center were not medically necessary for treatment of this patients medical condition. There is no documentation to support that a less intensive treatment, such as home-based comprehensive applied behavioral analysis, was tried without successful improvement of symptoms. Moreover, there is a lack of data demonstrating that cognitive behavioral therapy  is effective to address anxiety and obsessive compulsive tendencies in a two-year-old patient with mild-to-moderate autism spectrum disorder. Published reports supporting the benefits are in children ages seven and older, and usually with high functioning autism. Abramowitz and colleagues reported that CBT can be ineffective for many patients with obsessive compulsive disorder. Moreover, Hybel and colleagues found that executive function determines the response to CBT for children with obsessive compulsive disorder. Overall, the medical literature suggests that a two-year-old patient lacks the executive function to adequately engage in CBT. Given these findings, the services provided by the Early Childhood Treatment Center were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for shoulder surgery (CPT 29807  arthroscopy, repair of SLAP [superior labrum anterior and posterior] lesion; CPT 29826  arthroscopy, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release). Findings:  The physician reviewer found that Erickson and colleagues noted that, Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within our practice have decreased. The average age of patients undergoing SLAP repair is decreasing, and most SLAP repairs are performed for type II SLAP tears. The records provided for review document that this patients MRI findings were equivocal for a labral tear. The patient has reported multiple subluxation episodes since a prior dislocation. However, on physical examination, the patients range of motion and strength are normal. In addition, there is a lack of documentation that the patient has been treated with nonsurgical modalities to support an indication for surgical intervention. Therefore, the requested shoulder surgery (CPT 29807  arthroscopy, repair of SLAP lesion; CPT 29826  arthroscopy, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release) 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 orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator for treatment of the enrollees medical condition. Findings:  The physician reviewers found that The patient has nasal obstruction and erythema of the hypopharynx on examination which is likely due to his reflux and/or smoking. Nasal obstruction worsens OSA. Treatment of the nasal obstruction with medication or surgery is indicated. In addition, the patient likely suffers from laryngopharyngeal reflux (LPR). Treatment of LPR and the nasal obstruction can help the patient tolerate the CPAP device. Furthermore, there is a lack of evidence showing that the patient has tried other treatment options such as bi-level positive airway pressure (BiPAP) or automatic positive airway pressure (APAP) devices which are generally more tolerated than CPAP. Final Result: The reviewers determined that the requested device is 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: Physician reviewers number one, two, and three are board certified in otolaryngology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male has requested past and future coverage for Viagra 100 mg tablets for treatment of his medical condition status post prostatectomy.  Findings:  The physician reviewer found that erectile dysfunction (ED) after radical prostatectomy is a known complication. An individual patients ED symptoms may spontaneously improve over time or respond to medical therapy. The program of penile rehabilitation with phosphodiesterase type 5 (PDE5) inhibitors, such as Viagra and Levitra, has been evaluated for many years. Overall, varying results and study designs have not shown the penile rehabilitation program to result in improved health outcomes. One randomized multicenter parallel group study across 87 centers from Montorsi and colleagues evaluated the efficacy of vardenafil (Levitra) in patients with ED following nerve sparing radical prostatectomy. The authors compared Levitra dosed nightly versus on demand against placebo. The authors concluded that Levitra was efficacious when used on demand supporting a shift toward on demand dosing. Given that the Health Plan has authorized the formulary alternative Levitra, the requested Viagra has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested Sutent for the treatment of her condition. Findings:  The physician reviewer found that Sutent is an oral multi-targeted tyrosine kinase inhibitor. It has been approved for the treatment of metastatic renal carcinoma. A single phase II study in breast cancer has shown the drug to be modestly active. There are many other standard options for the treatment of breast cancer that would be appropriate for this patient. Sutent is not medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni 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.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  These guideline recommendations are 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 with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her medical condition. Findings:  Two physician reviewers found that PTNS was not likely to be more effective for this patient than other available options. According to the American Urological Association (AUA) guidelines for the treatment of overactive bladder, PTNS is considered an acceptable third-line treatment option when first-line and second-line options have been tried and failed. In this case, there is a lack of documentation demonstrating that first-line and second-line treatments have been tried and failed. Therefore, the services at issue were not likely to be more beneficial than standard medical therapy in this clinical setting.Final Result: Two reviewers determined that the services at issue were 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: The three reviewers are board certified in urology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested implantation of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea (OSA).  Two physician reviewers found that OSA can have significant effects on both personal and public health. CPAP has demonstrated excellent efficacy for patients with OSA and has long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in a research setting, the results of a large multicenter, prospective trial were recently published. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This novel approach is the first to combine sleep surgery techniques with a titratable medical device for the treatment of OSA. This patient has been treated with surgery for his OSA. He is status post tonsillectomy and UPPP, and has failed to achieve adequate results with CPAP. Based on these findings, the requested implantation of a hypoglossal nerve stimulator is likely to be more beneficial for this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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: All three reviewers are board certified in otolaryngology 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 59-year-old male enrollee requested Norco (hydrocodone-acetaminophen) for medical treatment of his rotator cuff tears and lumbar disc herniations.  Findings:  The physician reviewer found that the requested Norco (hydrocodone-acetaminophen) is not medically necessary for treatment of this patients medical condition. The records indicate that the patient requires two tablets of Norco every four hours as needed. This type of narcotic at this dosing is currently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. Additionally, the dose of Norco poses a risk for acetaminophen toxicity. This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy under the close monitoring of a certified pain management physician (Fishman).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalizations for infusions of intravenous immunoglobulin (IVIG) every two weeks for treatment of her common variable immunodeficiency.   Findings:  The physician reviewer found that a review of the documentations including vital sign flow sheet, treatment records and discharge summary do not support that the admission criteria have been met in this clinical setting. Overall, there are insufficient data to show hemodynamic instability, high fever or high risk infection, severe pain, systemic drug or toxin reaction, frequent inpatient monitoring, neurologic findings, acute renal failure, acute blood loss or emergency procedure occurred during hospitalization. Thus, the requested inpatient hospitalizations for infusions of intravenous immunoglobulin (IVIG) every two weeks are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in internal medicine with sub-specialty certification in allergy and immunology 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 male enrollee requested Harvoni for 8 weeks for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Those with substantial fibrosis (defined as Metavir F2 or higher) should be given priority for therapy in an effort to decrease the risk of clinical consequences such as cirrhosis, liver failure, and hepatocellular cancer. Given that the patient has a Metavir score of F2 with genotype 1 infection, Harvoni for 8 weeks is medically necessary for treatment of this patients medical condition.