Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested Rituxan for the treatment of his chronic inflammatory demyelinating polyneuropathy. Findings:  Three physician reviewers found that although Rituxan is not first-line therapy for CIDP, there is literature that supports its use in this population. In this particular case, the patient has failed multiple prior standard first-line therapies and some second and third-line therapies. The patients neurologist is rightly concerned about the patients disease progression and the long-term effects of IV steroid use. Given this clinical history, it is medically reasonable to treat this patient with Rituxan.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture. Authors noted that, the existing evidence suggests that most acupuncture therapies combined with other therapies, are effective in decreasing pain and in improving physical function. Similarly, researchers concluded that a course of acupuncture treatment is a reasonable option for a patient with chronic pain. This patients records document that she completed at least six sessions with substantial benefit in terms of ability to sleep and perform ADLs. Additional acupuncture could address the patients medical condition with further functional improvement. Due to the chronicity of this injury, the use of passive care should be limited. Self-management strategies like an independent exercise program, self-imposed restrictions, and proper biomechanics are supported by the peer-reviewed medical literature to stimulate self-reliance. Given these findings, an additional six sessions of acupuncture are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has serious risk of harm, due to self-harm prior to admission, and continued to demonstrate impulsivity and rule breaking at the RTC. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients conflict with parents and with peers at the RTC, without physical aggression. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of substance abuse. The patient reported using cannabis heavily at home, continued to test positive for THC at the RTC, and was reported trying to gain access to confiscated cannabis while at the RTC. The substance abuse contributed to other impulsive behaviors. In terms of stress of the recovery environment, the records support a score of 2. The patient has a mildly stressful environment due to struggles with performance expectations at home. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. She demonstrated continued substance use and depressed mood despite multiple prior experiences with IOP, OP, and psychiatrist hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to her rule-breaking at the RTC. Thus, the patient has a total score of 22. Given the patients risk of harm, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient was and is receiving at the residential treatment center. Therefore, psychiatric RTC services were and are medically necessary for the treatment of this patient. 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 sub-specialty certification 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

The representative of a deceased 65-year-old female enrollee has requested reimbursement for skilled nursing facility (SNF) services the enrollee received for the enrollee who had lung cancer. Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that the patient had severe cognitive impairment and altered consciousness while at the SNF facility. She was unable to participate in therapy. She did not have symptoms that required daily skilled nursing management. Hospice care would have been appropriate during the period in question.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested for oxygen for treatment of his diabetes mellitus, hyperlipidemia, sleep apnea, asthma and obesity.  Findings:  The physician reviewer found that the documentation provided fails to establish the medical necessity of the requested oxygen in this patients case. The documentation does not demonstrate a complete workup by a sleep specialist.  Based upon the medical records, the current medical evidence does not support the requested oxygen in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary artery tomography scan. This patient presented with a history of lipid levels within the familial hyperlipidemia range and a family history of sudden cardiac death in her mother, father, and brother. The patient underwent evaluation with coronary artery calcium scoring with coronary artery tomography. Based on current guidelines published by the American College of Cardiology (ACC) and American Heart Association (AHA), for patients with borderline or low 10-year atherosclerotic cardiovascular disease risk, coronary artery calcium scoring can provide valuable, actionable information (Greenland, et al.). When a patients coronary artery calcium score is zero, this obviates the need for lifelong statin therapy. Per Greenland and colleagues, scoring has emerged as a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions such as statins and aspirin. Given these findings, the coronary artery tomography scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the coronary artery tomography scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were 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 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is 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 57-year-old female enrollee has requested anesthesia administered during a colonoscopy for treatment of her colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient did not present with a significant history which would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts, and comorbid conditions which would place the patient at risk during the procedure.  Per the submitted documentation, there is no documentation of comorbid conditions which would have placed the patient at risk for complications requiring the need for monitored anesthesia care.  The current medical evidence does not support monitored anesthesia care in this clinical setting.  In sum, monitored anesthesia administered during the colonoscopy on the date in question was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated insulin delivery for treatment of the enrollees diabetes type I. Fulfills Findings:  The physician reviewer found that The requested device is considered investigational as long term studies are not available. There is not enough long term data to show that it is superior over other monitoring devices. At this time, the incremental benefit of automated closed loop control of insulin administration is unclear. There is currently no long term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGM. However, due to the non-randomized study, design and lack of a control arm, statements pertaining to its efficacy are limited. Therefore, the requested automated insulin delivery device is not likely to be more beneficial than the standard options for managing this patients blood glucose levels. Final Result: Two out of three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five year-old male diagnosed with an expressive/receptive language disorder is requesting authorization continued speech therapy.  Reviewers Findings:  The reviewing physician found that because of the lack of information provided, there is no evidence submitted demonstrating that continued therapy would benefit the patient or could be considered medically necessary.  The Health Plan denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested for naltrexone 3mg with lactose for treatment of her breast cancer.   Findings:  Three physician reviewers found that there is a lack of peer-reviewed literature indicating a benefit of this drug for this patients condition. This medication is not indicated for the management of breast cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of both knees for evaluation of her medical condition.  Findings:  The physician reviewer found that current medical evidence supports the requested services in this patients case.  There is no evidence of fracture on a recent x-ray series, and there are no clinical signs of infection.  However, the patient complains of severe pain in both knees, and the radiographs indicate the presence of a joint effusion.  The presence of such fluid indicates increased intra-articular pressure, and current guidelines support MRI in this clinical setting.  All told, the requested MRI of both knees is medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The physician 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

The patient has requested authorization and coverage for Tepezza (teprotumumab-trbw) infusions every 21 days for eight total doses (dose 1: 10 mg/kg; doses 2-8: 20 mg/kg). Graves ophthalmopathy is a potentially sight-threatening ocular disease that occurs in patients with hyperthyroidism or a history of hyperthyroidism due to Graves disease (Bahn). Initial treatment with glucocorticoids has demonstrated limited efficacy and presents safety concerns. Tepezza is a monoclonal insulin-like growth factor-1 receptor (IGF-1R) antagonist that has demonstrated proptosis reduction, which is similar to that seen with decompression surgery. This patient is a good candidate for Tepezza, particularly because he has failed glucocorticoid therapy. Given these findings, the requested Tepezza (teprotumumab-trbw) infusions every 21 days for eight total doses (dose 1: 10 mg/kg; doses 2-8: 20 mg/kg) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of her medical condition. Findings:  Three physician reviewers found that the patient does not currently have a breast cancer diagnosis, nor does she have ovarian cancer in her family history.  There is no clinical benefit for the requested diagnostic testing at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male enrollee has requested for an annual DXA bone density study for evaluation of his status post lung transplant. Findings:  The physician reviewer found that there were no adverse changes from previous bone density testing. There is no indication that the patients health status has changed. Further, there is no indication that the patients medication doseage has changed. Bone density testing every two years is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a seven-year-old male with multiple diagnoses relating to cognition with a primary diagnosis of attention deficit hyperactivity disorder (ADHD). The patient has been seen by a speech therapist who has documented a significant speech and cognitive delay. Additionally, neuropsychological testing has been performed. The patients neuropsychologist recommended ongoing speech and language therapy. The Health Plan indicates that continued speech therapy is not medically indicated.Based upon review of the pre-and post-speech therapy documentation, it is apparent the patient has regressed is some areas despite therapy. In addition, there is not sufficient literature evaluating speech therapy as a primary treatment for ADHD. Typically, medications are used as the primary treatment for this disorder with speech therapy used as an adjunctive therapy. Therefore, I have determined that additional speech therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should be evaluated by a developmental pediatrician or pediatric psychiatrist to determine if medications are warranted. If it is determined that medications are warranted, the request for additional speech therapy should be reconsidered, as it may be an appropriate adjunct therapy. However, given the patients previous evaluations, additional speech therapy without use of medication is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested neurofeedback therapy for treatment of her major depression (and other diagnoses).   Findings:  Three physician reviewers found that while neurofeedback may be a valuable treatment module for neuropsychiatric disorders, further controlled studies are necessary to establish its efficacy and mechanisms(Heinrich and colleagues). Additionally, the efficacy of neurofeedback has to be assessed separately for each disorder, which is not possible in this patients case. Holdcraft and colleagues note there are limited randomized controlled trials in the literature, and that well designed studies are lacking when it comes to biofeedback to treat fibromyalgia. In summary, while neurofeedback/biofeedback is emerging, there is limited data to conclude that neurofeedback is likely to be more beneficial than other standard treatment modalities available for the treatment of this patients diagnoses.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week course of Harvoni for treatment of her chronic hepatitis C virus genotype 1a. Findings: Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Therefore, although Harvoni is clinically appropriate in this setting, the requested duration of 12 weeks of therapy is not medically necessary given that the patient is treatment-naive and has a viral load of less than 6 million IU/mL. As such, the requested 12 week course of Harvoni is not medically necessary. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.