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

Nature of Statutory Criteria/Case Summary: An enrollee has requested subcutaneous implantable cardioverter defibrillator for treatment of the enrollee, who has been diagnosed with hypertrophic cardiomyopathy.  Findings: Two physician reviewers found that there are sufficient support for the requested device in this clinical setting.  This patient has hypertrophic cardiomyopathy and risk factors for sudden cardiac arrest including unexplained syncope, family history of arrest in first-degree relative with the same condition, and non-sustained ventricular tachycardia on monitoring.  In this circumstance, defibrillator placement is considered standard accepted practice in the medical community.  Current guidelines endorsed by several national organizations consider defibrillator placement appropriate in this setting.  Both types of defibrillators (traditional endocardial lead systems and subcutaneous systems) accurately detect ventricular arrhythmias.  Per the records, placement of a subcutaneous defibrillator has potential long-term advantages in this particular circumstance.  For this young patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur, then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Furthermore, his condition of hypertrophic cardiomyopathy does not predispose him to symptomatic bradycardia that may require backup pacing only provided by a standard endocardial defibrillator lead.  Therefore, the requested subcutaneous implantable cardioverter defibrillator is likely to be more effective than other treatment options.Final Result: Two reviewers determined that the requested device 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: 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: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary incontinence. Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available options. PTNS and SNS are considered third line treatment options for overactive bladder (Gormely et al). Based on the medical records submitted for review, there is a lack of evidence that the patient has tried and failed or is intolerant to first and second line treatments, such as behavioral therapies and antimuscarinic therapy. Therefore the services at issue were not and are not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested circumcision for treatment of the enrollees uncircumcised penis.  Findings: The physician reviewer found that children with normal hygiene and no history of infection or inflammation of foreskin do not have a medical necessity for circumcision. Additionally, there is a lack of medical literature or experience that links any changes in self-esteem from differences in appearance between siblings. Finally, elective circumcision can be performed under local anesthesia when children are older, generally, between 8 and 10 years old, foregoing the general anesthetic required in a patient. Accordingly, the requested circumcision is not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 urology with sub-specialty certification in pediatric urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. This patient was diagnosed with multiple mental health concerns which affected her activities of daily living.  She was admitted to the RTC at a time when she was showing behaviors which were dangerous to herself and to others. Prior to RTC level of care, the patient tried and failed multiple different avenues of outpatient care and care at less restrictive levels. Her behaviors were escalating and had not abated with treatment at these less restrictive levels. While at the treatment facility, the patient started to respond positively to therapy and the structure of the program. Over time, she began to implement the lessons she was learning which allowed her to modify her own behaviors. She was learning to be successful at behavioral management, a discipline that was absent at the time of her admission at RTC. The submitted records indicate that this patient was benefitting from the structure of the program. As noted in the documentation provided, by the time of her graduation, her anxiety was well managed and controlled with current medications, Buspar in particular.  Her behavior had settled. She was no longer a danger to others and she was no longer exhibiting self-injurious behaviors. She was no longer pulling her hair out and she was calmer. She learned skills, including self-efficacy. The patient was subsequently able to establish positive relationships at home and with friends, though this was indicated to still be a bit of a struggle for her at the time of her discharge. The patient had reported that she was going to continue to work on maintaining positive relationships. As such, the records show that this patient benefited from RTC services. Therefore, the services at issue were medically necessary for treatment of this patients medical 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occipitocervical fusion. The records provided for review document that this patient has a history of occipital neuralgia secondary to post Chiari decompression procedures. Occipital neuralgia is characterized by severe pain in the distribution of the greater auricular nerve. Although patients with occipital neuralgia may require surgery, such as laminectomy and fusion, there is a lack of evidence to support the efficacy of occipitocervical fusion for this syndrome.  Researchers found that, minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. The authors cautioned that, Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options. There is adequate data demonstrating that occipitocervical instability may be treated with occipitocervical stabilization and fusion. However, this patients records do not document the presence of occipitocervical instability. Given these findings, the requested occipitocervical fusion is not medically necessary for 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 neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a special blood test (Guardant 360 biopsy-free tumor sequencing test) for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that National Comprehensive Cancer Network guidelines endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling is considered standard of care. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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 55-year-old female enrollee has requested physical therapy for treatment of her sacroiliac joint dysfunction.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested therapy.  There is a lack of high-grade evidence-based literature that establishes a need or benefit of physical therapy after platelet-rich plasma (PRP) injections.  In this case, the patients pain symptoms have increased following PRP.  She has already undergone physical therapy, without significant or sustained symptomatic or functional benefit per the treating physical therapist.  The patient has undergone extensive physical therapy to date and should already be independent with a home exercise and self-management program.  She does not have impairments that would preclude performance of an independent exercise program without physical therapist guidance.  No marginal benefit in the patients clinical course or outcomes would be expected with ongoing formal physical therapy versus an independent program.  All told, continued physical therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50 mg-100 mg for 16 weeks for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks (as requested) when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment level of care provided during the dates of service in question. Findings:  The physician reviewer found that, due to the lengthy history of drinking and increased reports of consumption, a residentially-based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of the first date of service in question.  First, the absence of significant comorbidity supported a less restrictive setting.  The patient completed detoxification and there was no evidence of the emergence of late alcohol withdrawal symptomatologies.  The patient was medically stable.  He did not have a degree of psychiatric impairment that would have necessitated a residential treatment setting. Second, the patient embraced recovery principles and was motivated in his quest for sobriety.  He was noted to be motivated for sobriety in a different way than he has been before  By the date of service in question, he had completed a month of residential treatment and had been actively participating in groups and engaged with a sponsor.  He had the availability of safe and sober housing with his parents.  He had no other addictions besides alcohol.  Aside from the failed outpatient services, the patient had no prior history of chemical dependency treatment in an intermediate setting such as an intensive outpatient or partial hospital program.  Further, he had not previously been prescribed long-acting injectable naltrexone, which far outperforms the oral preparation as an anti-craving medication.  All of this is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate at the time.   Thus, the residential treatment provided during the dates of service in question was not medically necessary for the treatment of this patient. 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 Viekira Pak for treatment of her hepatitis C virus. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the AASLD/IDSA guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials and is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly Dialectical Behavior Therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. This patient is being treated for adjustment disorder with anxiety and depressed mood. Based on review of the records provided, it is noted that this patient had mild symptoms reported on her patient questionnaire. The letter by the therapist did not state what the sessions were intended to accomplish other than making conclusions that this patients depression could decompensate into full-blown depression or agoraphobia. The treatment of adjustment disorder with anxiety and depression can be treated with different types of therapy with Dialectic Behavioral Therapy (DBT) being one method of treatment for this disorder as shown by the references noted. Based on review of the records provided it does not appear that this patient requires the requested treatment specifically, therefore the requested services are not medically necessary.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 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

A 62-year-old male enrollee has requested for PinPointe Footlaser therapy for treatment of his toenail fungus.  Findings:  The physician reviewer found that standard therapy for acute and chronic paronychia include topical and systemic antibiotics, topical antifungal agents, topical steroids, topical tacrolimus ointment, incision and drainage and surgical intervention, such as en bloc excision of the proximal nail fold or marsupialization of the eponychium. Standard treatment of onychomycosis includes topical and systemic antifungal agents as well as mechanical interventions to prevent fungal infections. At this time, it does not appear that there are any peer-reviewed studies in the literature regarding the PinPointe Footlaser system for treatment of onychomycosis. Although the manufacture of the device contends that laser surgery can be used for removal of infected toenails, there has been no study that confirms the claim that the PinPointe Footlaser system penetrates the nail plate and kills all fungus in one treatment. There are many standard therapies that have been proven to be effective in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg for treatment of the enrollees 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 (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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These 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 infection, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg is medically necessary for the 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 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.