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

A 59-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. According to the American Psychiatric Publishing Textbook of Psychiatry, TMS therapy is U.S. Food and Drug Administration (FDA) approved for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. There is a lack of documentation demonstrating the patient has failed an appropriate trial in the current episode of illness. The medications prescribed in this case were dosed conservatively at levels not considered to be minimally effective for depression. Additionally, the symptoms listed by the patients treating provider do not establish the presence of a major depressive episode. Further, there is no clinical documentation describing longitudinal psychiatric symptomatologies and subsequent functional impairment that would support TMS therapy. Considering the peer-reviewed literature, current practice guidelines and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospitalization provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided was medically necessary for treatment of the patients medical condition. The inpatient hospitalization was reasonably expected to improve the patients condition and prevent a more serious episode of illness for this patient with multiple intrapsychic conflicts and distorted schemas that exacerbated debilitating anxiety and clinical depression with atypical features, and fueled cyclical maladaptive patterns of behavior. Although the patient had showed some improvement in the first week, she had not championed the issues that prompted the admission. Indeed, she remained anxious and ruminative, and continued to sleep excessively. Further, she had yet to have any significant change in her medication regimen. The patient would have more than likely experienced a prompt deterioration if discharged. All told, inpatient psychiatric care was safe, appropriate and consistent with good medical practice in this case while the duration of services aligned with community standards. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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 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 authorization and coverage for F-18 fluciclovine positron emission tomography/computed tomography scan (PET/CT scan with Axumin). The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee who has a history of prostate cancer.Findings:  Upon review of available data, the use of F-18 fluciclovine PET/CT scan with Axumin is likely to be more accurate in the re-staging of the above patient as compared to standard re-staging consisting of bone scan and CT. 18F-fluciclovine was U.S. Food and Drug Administration approved in 2016 for the this patients specific clinical scenario of suspected recurrent prostate cancer in patients with elevated PSA after prior therapy. The recent National Comprehensive Cancer Network (NCCN) guidelines support its use in staging of suspected recurrent disease, specifically stating that F-18 fluciclovine PET/CT may be used to detect small volume disease in soft tissue. The studies have shown that fluciclovine PET is more sensitive to detecting residual prostate cancer than bone scan or conventional computed tomography (CT). Researchers specifically evaluated the use of fluciclovine PET/CT and its influence on postoperative radiotherapy treatment fields in patients with recurrent prostate cancer. They found that the results of a fluciclovine PET changed the radiation fields in 40.5% of the evaluated patients. Additionally, 4.8% of patients had radiotherapy withheld after the discovery of extra pelvic disease. The medical literature indicates that F-18 fluciclovine PET/CT is useful in restaging for suspected recurrent disease. The patient has already undergone previous pelvic radiation, thus further radiotherapy options with definitive intent are likely limited. Based on the above, F-18 fluciclovine PET/CT scan with Axumin is likely to be more effective when compared to conventional CT and/or bone scan for evaluating this patients medical condition.Final Result: All three reviewers determined the requested diagnostic procedure is 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:  One of the three reviewers is board certified in diagnostic radiology and is actively practicing. Two of the three reviewers are board certified in radiation oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for skilled nursing care of a licensed skilled nurse (HCPCS Codes G0300 and G0299). On review of the available medical records, the skilled nursing care of a licensed skilled nurse was and is medically necessary for treatment of this patient. Specifically, the skilled nursing services will help prevent disability and disease progression given the patients elevated risk of aspiration pneumonia due to her medically intractable epilepsy, severe gastroesophageal reflux, neuromuscular respiratory weakness, and inability to protect and clear her airway. She is also at risk of pressure sores as she is unable to reposition herself. The skilled nursing services will help prolong life and promote physical and mental health efficiency as these services will directly reduce the patients risk of decompensation. As noted by the American Academy of Pediatrics (AAP) guidelines, home skilled nursing is recommended for children with medical needs in Level 1, which include the need for frequent suctioning, oxygen therapy in connection with apnea monitoring, and nutritional support (Harris, et al.). This patient meets these criteria based on the available documentation. Fratantoni and colleagues noted that, children with medical complexity often require pediatric home health care to meet their daily intensive care needs and to live safely outside of the hospital. Similarly, Boss and colleagues reported that, for children with complex medical conditions, pediatric home health care is a chronic need. It is a clinical service delivered entirely outside of clinical settings, granting families unparalleled expertise regarding service quality. Given this support, the skilled nursing care of a licensed skilled nurse was and is medically necessary to prevent disease, disability, and other health conditions and their progression, to prolong life, to promote physical and mental health and efficiency, and to correct or ameliorate any physical or behavioral conditions. Therefore, the skilled nursing care of a licensed skilled nurse (HCPCS Codes G0300 and G0299) was and is medically necessary for treatment of this patient. 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 neurology 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni or in the alternative, Zepatier, for treatment of her hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1b patients should be treated with Harvoni or Zepatier. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al).  Harvoni was recommended by the patients provider as the preferred direct direct-acting antiviral for this patient. The proposed use of Harvoni is medically appropriate and consistent with AASLD/IDSA guidelines. For these reasons, treatment of hepatitis C with Harvoni is supported as medically necessary for treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested Harvoni 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 67-year-old female enrollee has requested panniculectomy and abdominoplasty for the treatment of her excess skin. Findings:  The physician reviewer found that generally accepted medical necessity criteria for panniculectomy and/or abdominoplasty requires evidence of chronic rashes, skin breakdown, and recurrent infections of the skin under the pannus that has failed to respond to conservative treatment. The submitted medical records do not include documentation of such findings. None of the patients office visits indicated treatment of skin conditions under the pannus or follow-up to check her response to treatment. There is a lack of dermatology or primary care physician (PCP) notes which diagnose and treat skin related conditions with failure of conservative treatments over a period of months. Furthermore, the submitted photographs do not show the undersurface of the pannus to document the pre-operative skin condition. All told, there is a lack of sufficient evidence of physiologic dysfunction to warrant panniculectomy and abdominoplasty from a medical standpoint.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested psychiatric services on an emergent or urgent basis.  Findings: The physician reviewer found that based on the documentation submitted for review, the patient was not experiencing a psychiatric emergency medical condition as she was not in immediate danger to herself or others or unable to utilize, food, shelter, or clothing due to her mental disorder. The patient was not endorsing symptoms of suicidal or homicidal behavior, she was not psychotic, and she was able to perform all her activities of daily living. However, it has been established that criteria for urgently needed services were met. In this case, the patient stepped down from acute level of care to partial hospitalization program (PHP) level of care. The record from the patients acute inpatient admission prior to this date indicates that the patient was feeling very stressed, anxious and depressed.  The discharge summary indicated that as long as she remained in a structured environment, she was shielded from these stressors and could do quite well.  However, the treatment team cautioned that her risk of suicide would markedly increase as soon as she was re-introduced to these environmental stressors. Therefore, admittance to PHP level of care was urgently needed to prevent serious deterioration of the patients health upon discharge from acute level of care. While participation in a PHP program was a necessary component of the patients post-acute treatment, based upon the psychiatric exam, the patient was sufficiently stable to be discharged from her current program to another program at that time. The patient was noted to be calm and cooperative and reported that she was feeling better. She was also fully compliant with her medications and denied any side effects.  All told, the PHP services were urgently needed services.  Final Result: The reviewer determined that the patient was not experiencing a psychiatric emergency medical condition. However, the PHP services the patient received were urgently needed services. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested fetal cardiac intervention procedure (in utero balloon pulmonary valvuloplasty) for treatment of her fetus prenatally diagnosed with pulmonary atresia. Findings:  Two physician reviewers found that in the subgroup of pulmonary atresia and intact ventricular septum (PA/IVS) infants who develop hypoplastic (small) right ventricles, there is an increase in mortality and the need for three-stage operations for uni-ventricular repair. Peterson and colleagues discussed the clear fetal echocardiogram (ECHO) guidelines that predict poor outcomes based on poor right ventricle growth resulting in hypoplastic right ventricles. Thus, the goal of intervention is to improve the right ventricle growth such that the result is a two-ventricle outcome. Given the results of Tworetzky and colleagues fetal cardiac interventional program, the proposed procedure, although high risk, is likely to be more efficacious in the setting of severe tricuspid regurgitation and impaired RV growth, than any other standard procedure including post-natal surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Maxalt for treatment of her migraines. Findings: The physician reviewer found that the medical records provided for review document headache frequency, severity, and associated symptoms consistent with a diagnosis of migraine headache. The current peer-reviewed medical literature supports Maxalt for abortive treatment of migraine headaches. Maxalt has been approved by the U.S. Food and Drug Administration (FDA) for abortive treatment of migraine headache (Becker; Kassem). Moreover, Maxalt is approved for use up to two times per week. Given this support, the requested Maxalt is medically necessary for treatment of this patients migraine headaches. 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 neurology with sub-specialty certification in pain management 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 forty-seven year-old female with bilateral arm pain and weakness that has progressively worsened is requesting authorization for a muscle biopsy.  Reviewers Findings:  The reviewing physician found that Muscle biopsy is not medically indicated in the context of the patients isolated pain and the procedure might potentially exacerbate the patients progressive, chronic pain syndrome.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female who is 15 months status post right mastectomy for breast cancer with 7 of 19 positive lymph nodes harvested at lymphadenectomy. She underwent postoperative chemotherapy and a course of radiation therapy, which ended in December 2003. The patient sought reconstruction of her chest wall deformity and was evaluated by a plastic surgeon who recommended a TRAM flap reconstruction. The patient sought a second opinion from the plastic surgeon who had placed her breast implants ten years earlier. He suggested the use of a latissimus dorsi myocutaneous flap with an implant to match the remaining left breast. The patient is considering a left breast mastectomy because of fear of bilateral disease. The Health Plan has denied authorization for the latissimus dorsi flap repair on the basis that it is not medically necessary. The TRAM flap reconstructive procedure has been authorized.The procedures proposed for the patients breast reconstruction post mastectomy, post radiation therapy (expander/implant, TRAM flap, and the latissimus dorsi flap/implant) all are negatively impacted by the post radiation changes to the respective vascular pedicles or local tissue. The choice of procedure is essentially guided by the knowledge of the patients treating surgeon. There is no objective evidence that the requested procedure is more advantageous than the procedure recommended by the patients treating surgeon and authorized by the Health Plan. The procedure authorized by the Health Plan is medically reasonable and appropriate. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested magnetic resonance imaging (MRI) scan of the orbitals, face, and neck, and revision of arm nerves for evaluation of his right upper extremity neurologic symptoms. Findings:  The physician reviewer found that the MR imaging and subsequent MR neurography for high resolution imaging of the aforementioned structures allowed for minimally invasive treatment of the patients neurogenic refractory thoracic outlet syndrome. Given the numerous previous procedural failures and difficulty in diagnosing this patients disorder, the MR imaging of the neck and brachial plexus along with the muscles and soft tissue contributing to the impingement and neurogenic thoracic outlet syndrome were medically indicated and should be reimbursed. However, the medical necessity of the MR imaging of the face, orbits or head outside of that region has not been established as medically necessary in this clinical setting. With regard to the revision of arm nerves, the procedure was medically necessary as it was indicated to effectively revise the resection and decompression.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for chemoembolization of the hepatic artery with Carmustine and Sutent oral chemotherapy for treatment of her choroidal melanoma with liver and lung metastases.  Findings:  The physician reviewer found that a study by Bedikian and colleagues dating back to 1995 studied 201 patients who were treated with chemoembolization with cisplatin-based regimens and realized a 36% response rate. In addition, this conclusion is consistent with the findings by Leyvraz and colleagues who reported on 12 patients out of 30 who experienced a positive response. More recently, a study by Sharma and colleagues noted that survival was improved in patients treated with chemoembolization. Thus, chemoembolization has become an accepted treatment for ocular melanoma metastatic to the liver and is therefore clinically appropriate therapy for this patient. With regard to the request for Sutent as systemic chemotherapy, there is a lack of clinically significant data demonstrating that this agent is useful in the treatment of metastatic ocular melanoma. Sutent is currently being studied as part of an early phase clinical trial. At this time, the potential benefit of Sutent in this particular setting remains speculative. In the absence of evidence demonstrating that Sutent is likely to result in a positive response in this situation, the medical necessity of this agent is not established.