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

A 26-year-old male enrollee has requested residential treatment for treatment of his opioid dependence and cannabis dependence. Findings:  The physician reviewer found that the medical records indicate that his level of abuse was considered high-risk, and he was referred to inpatient treatment with a notation that he would be accepted back into treatment once he completed a 30-day program. The records also indicate previous attempts at treatment a few years ago.  The medical records noted daily substance abuse, with significant functional impairment. Following acute detox, he was transferred for residential treatment. Admission records indicate he was depressed and anxious, with poor judgment. His comorbid issues included chronic back pain.  The patient required psychotropic medication adjustments while in residential treatment for post acute withdrawal syndrome. Given the patients failure at lower levels of care, escalating substance abuse, inability to abstain, significant functional impairment, poor judgment and poor response to prior treatment attempts, treatment in a 24-hour residential setting was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old male enrollee has requested Gemzar and Taxotere for the treatment of his recurrent metastatic leiomyosarcoma. Findings:  Three physician reviewers found that the relevant medical literature including the articles submitted with this appeal demonstrates that there is sufficient support for the proposed regimen in this case. Gemzar and Taxotere is standard oncology practice for treatment of leiomyosarcoma. The patient is an appropriate candidate for the requested regimen.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco and cortisone injection for treatment of the enrollees medical condition. Based on the documentation submitted for review, Norco and cortisone injection have not been established as medically necessary for treatment of the patients medical condition. In this case, the patient has a history of non-compliance with follow-up visits and imaging studies for treatment of his left shoulder. The patients providers have advised against continued opioid use and cortisone injections. In this clinical setting, the providers recommendation for treatment with anti-inflammatory medications is medically reasonable and appropriate. In addition, the patient should be re-evaluated by orthopedics to discuss treatment options prior to treatment with cortisone injections. As such, the requested services are not medically necessary for treatment of the patients medical condition.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 anesthesiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy, including simulation and magnetic resonance imaging for treatment planning.  There is a lack of clinical evidence to suggest that proton beam radiation therapy will improve toxicities or improve local control compared to standard treatment with photons. There is a lack of phase 3 trials comparing outcomes of photon therapy versus proton beam radiation therapy for patients with cholangiocarcinoma. In this patients case, standard treatment with photon therapy is appropriate. Thus, proton beam radiation therapy, including simulation and magnetic resonance imaging for treatment planning was not and is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested for intensive outpatient services for treatment of her condition. Findings:  The physician reviewer found that the American Psychiatric Association treatment guidelines for the treatment of an eating disorder, the trauma work and processing of the memories of sexual abuse did not meet the eating disorder intensive outpatient level of care guidelines.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested Sovaldi and Ribapak for medical treatment of her hepatitis C genotype 2a. Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, Sovaldi and Ribapak is the only recommended regimen for treatment-naive patients with hepatitis C genotype 2, regardless of eligibility for interferon therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A patients parent has requested authorization and coverage for IVIG Gamunex-C. This patient has failed multiple pharmacological and behavioral treatments considered standard therapy for PANS. He continues to exhibit severe disabling symptoms and a progressive course. Current clinical guidelines based on consensus statements and limited research, support the use of multiple immunomodulatory therapies in combination in severe and progressive cases. For patients with severe refractory cases that fail first-line therapy, immunoglobulin therapy in combination with other pharmacological agents is likely to result in better outcomes with fewer relapses. Given this support, the requested IVIG Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IVIG Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in neurology with special qualification in child neurology 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hydrocodone for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In a retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose and short-acting opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, hydrocodone is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 patient is a 49-year-old man with a 28-year history of type 1 diabetes mellitus now under good glycemic control on an insulin pump. The patient indicates he tests his blood glucose by home monitoring (SMBG) 10 to 14 times a day. His A1c on 3/5/04 was 5.6%. The patient has requested authorization for 10 to 12 test strips per day to sustain the level and intensity of monitoring required by his active work and lifestyle. The Health Plan indicates more than seven test strips per day are not medically necessary for management and control of the patients diabetes.The patients endocrinologist indicates that the patients frequent self-monitoring has allowed the patient to maintain his good control. It is extremely rare for patients to require more than seven SMGB values a day. Although testing before meals, at bedtime, and occasionally at 3:00 to 4:00 a.m. is standard practice for intensive regimen testing, it is also suggested to test before physical activity and other activities such as driving and using machinery. Additionally, the role of postprandial blood sugar testing in diabetes control is being increasingly recognized.Because of this patients continuously changing and challenging lifestyle, he requires more frequent monitoring in order to maintain near normal blood glucoses on his intensive insulin regimens. Therefore, I have determined that 10 diabetic test strips per day are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patients resultant blood glucose values and the actions taken to modify his insulin or activity should be documented to his endocrinologists satisfaction in order to maintain this level of testing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for residential psychiatric care. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.At issue in this case is whether the residential psychiatric care for the dates 11/14/17 to 12/5/17 was medically necessary for treatment of the enrollees behavioral health condition.The preferred level of care is the least intensive level that meets treatment objectives while providing safety and security for the patient. There were no significant post-acute withdrawal symptoms. The patient was not a danger to himself or others. He did not show significant emotional, behavioral, cognitive or impulsive symptoms to support residential level of care. The patient was able to perform activities of daily living independently. The patient was motivated and appeared to be working the program. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The patient was stable medically and psychiatrically. He was beginning to show insight into his behavior, learning to identify triggers, was working on his inventory, and was in the contemplative stage. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Although the patient continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. The patient could have been stepped down to an ambulatory level of care, with consideration for medication assisted treatment. The patient could continue recovery in the ambulatory level of care in conjunction with a 12-step program. Relapse risk in and of itself is not a reason to keep a patient in the residential treatment setting. Therefore, the requested residential psychiatric services were not medically necessary. 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 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: An enrollee has requested authorization and coverage for 168 hours per week of home health care services for treatment of the enrollees Werdnig-Hoffman disease, idiopathic scoliosis, respirator dependent and gastrostomy tube (G-tube) status. Findings:  The physician reviewer found that Werdnig and Hoffman disease is a disorder of progressive muscular weakness beginning in infancy characterized by loss of anterior horn cells. Home care nurses provide specialty care to adult and pediatric patients with medically complex needs. The most complicated patients require the use of a ventilator in order to maintain adequate breathing. Patients with this level of need require a competent nurse with current knowledge of and experience with the latest medical technology. In this case, the patient requires 24-hours per day nursing care as he is ventilator dependent, requires frequent repositioning, G-tube feedings, medication administration, and ongoing active skin care. He also needs repositioning every two to three hours, skin assessments, medication management, and help with transfers. Given the patients medical condition there is potential for decompensation which is likely to occur with a decrease in home health services. Final Result: The reviewer determined that the requested services 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 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 occipital nerve block injections and prospective authorization and coverage for occipital nerve block injections every three months. According to the International Headache Society (AHS) classification, occipital neuralgia is defined as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves. An observation report found that the use of greater occipital nerve blocks markedly decreased migraine attack frequency, severity and duration, and analgesics use compared with baseline symptoms in patients with chronic refractory migraines. The authors reported that the results suggest that greater occipital nerve blocks resulted in reduction in pain severity and frequency, and use of analgesics for up to three months after the third injection. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Treatment with occipital nerve blocks have helped in decreasing the frequency of the patients migraine headaches. All told, the occipital nerve block injections provided, and occipital nerve block injections administered every three months, were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the occipital nerve block injections provided, and occipital nerve block injections administered every three months, were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were and are 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 reviewers 1, 2, and 3 are board certified in neurology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting reimbursement for the partial hospitalization program (PHP) services provided for 21 days, and the intensive outpatient program (IOP) services provided for 15 days. The Health Plan denied the partial hospitalization program services for all days and the intensive outpatient program for all days as not medically necessary for the patients behavioral health condition. Findings:  The physician reviewer found that on admission to PHP, the patient did not require monitoring for post-acute withdrawals. Methamphetamine does not require detoxification and his last use of marijuana was 10 days prior to admission. The patient was medically stable and did not require five days per week of medical observation.  There were no barriers to recovery on an outpatient basis.  He had a sober and supportive recovery environment.  The patient denied psychiatric issues on admission.  He was not a danger to himself or others.  The patient had no functional impairments in activities of daily living, and he had no psychiatric issues requiring monitoring at the PHP level of care. During the dates of IOP services, the patient was not a danger to himself or others. His environment was conducive to recovery and his spouse was sober and supportive. The patient was medically stable and had no emotional or impulsive conditions requiring acute management beyond the outpatient setting.  He had no functional impairments in activities of daily living.  There were no barriers to recovery at an outpatient level of care.  There were no acute stressors or crisis situations preventing him from continuing treatment at an outpatient level of care.  The patient was already sober and participating in 12-step meetings, and did not require enhanced sobriety education beyond the outpatient setting.Final Result: The reviewer determined the patient had no functional impairments in activities of daily living, and he had no psychiatric issues requiring monitoring at the PHP level of care. Therefore, the PHP services were not medically necessary and the Health Plans denial should be upheld. The patient was already sober and participating in 12-step meetings, and did not require enhanced sobriety education beyond the outpatient setting. Therefore, the IOP level of care was not medically necessary and 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: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested excision of right breast mass for treatment of the enrollees right breast mass.  Findings:  The physician reviewer found that based on review of the available records, a right breast ultrasound on the indicated date demonstrated fibroadenoma and was interpreted to be BIRADS category 3  probably benign finding, with short interval follow-up recommended. Clinical and ultrasound impression of a breast mass as fibroadenoma is only presumptive and requires confirmation by histology. In this patient, excision is also warranted to relieve pain. Thus, the requested excision of the right breast mass is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her medical condition.  Findings:  The physician reviewer found that according to the 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. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is 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.