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

A 19-year-old female enrollee has requested for residential treatment for treatment of her eating disorder, alcohol abuse and depression.  Findings:  The physician reviewer found that the patient continued to struggle with intrusive thoughts about disordered eating and body image. Additionally, there were significant symptoms related to her co-occurring disorders. There was an ongoing need for multiple medication adjustments.This level of care is consistent with the American Psychiatric Associations Practice Guidelines for the Treatment of Patients with Eating Disorders.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the requested clonazepam is medically necessary for treatment of the patients medical condition. A review of the records provided showed that the treating provider recommended tapering clonazepam by 25% every two to three months, and the patient was started on a trial of gabapentin 100mg three times a day for anxiety. The patient was undergoing supportive therapy and cognitive behavioral training as well as psychoeducation regarding the psychotropic medications. The patient was given relaxation therapy and was placed on Belsomra for insomnia. As noted in current medical literature, benzodiazepines are no longer considered to be first-line therapies because of the risks associated with chronic use. Given this concern for side effects, antiepileptic agents have been used more extensively for the treatment of anxiety. A review of the literature shows gabapentin to be an effective alternative for the treatment of anxiety. This patient was started on gabapentin, which has been shown to be safe and effective in the treatment of anxiety. The additional use of clonazepam is not indicated. Based on review of the records presented, clonazepam 1mg tablets is not supported as medically necessary for the treatment of this patients behavioral health condition.Final Result: The reviewer determined that the requested services 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 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 patient is a 58-year-old woman with SLE and bronchiectasis. According to the initial consultation note dated October 1991, the patient was first diagnosed in 1963. The patient underwent a partial left lung resection. The bronchiectasis was thought to be caused by multiple childhood respiratory infections.Sputum culture on 10/16/04 revealed scant pseudomonas, which was sensitive to IV antibiotics only and resistant to ciprofloxacin. The patient was started on inhaled tobramycin. According to a letter from the patients provider dated January 2005, the patient had clinically improved and was to continue on inhaled tobramycin.The Health Plan denied coverage for inhaled tobramycin on the basis it is not medically necessary for treatment of the patients medical condition.The materials submitted for review include a study by Barker et al. The study was a prospective, randomized, controlled trial comparing use of inhaled tobramycin versus placebo in clearing pseudomonas from patients with bronchiectasis. The authors found a decrease in pseudomonas in the inhaled tobramycin group and eradication after 6 weeks in 35% of the experiment group.Upon review of the records provided, the patients bronchiectasis seems to be limited to an area in the left lung. As such, it appears her previous course of inhaled tobramycin was likely sufficient to eradicate the pseudomonas. Therefore, based upon the information provided, continuation of inhaled tobramycin is not medically necessary at this time. As such, the Health Plans denial should be upheld at this time. However, sputum cultures should be obtained. If the pseudomonas colonization/infection is persistent then the patients request for inhaled tobramycin should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested desensitization therapies prior to renal transplant (IVIG, plasmapheresis and Rituxan.  Findings:  Two physician reviewers found that the currently available standard therapy for end-stage renal disease is a living donor kidney transplant. In this case, there is an ABO incompatibility (ABaB). The potential recipient has a mildly positive anti-A titer (1:16) with her donor. The patients treatment center has developed techniques to reduce the deleterious anti-ABO antibody and improve transplant rates among this population that was previously considered untransplantable in most cases. The proposed desensitization treatment with IVIG, plasmapheresis and Rituxan for ABO incompatible living kidney donor and recipients with relatively low anti-A titer is an acceptable and reasonable option. It is important to include Rituxan (anti-CD20 monoclonal antibody) if the recipient is not to undergo a splenectomy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old female enrollee has requested three hours of speech therapy per week for treatment of the enrollees autism and expressive/receptive language delay. Findings:  The physician reviewer found that there is extensive medical literature supporting the value of speech therapy for improvement of pragmatic speech in autistic children. At issue in this case is whether individual speech therapy at a frequency of three hours per week is medically indicated over individual speech therapy at a frequency of two hours per week, which has been authorized by the Health Plan.  There are few studies available regarding the appropriate intensity, duration, and frequency of therapy for speech impaired children with autism. In this case, the patient is currently receiving two hours of speech therapy per week, coupled with 24 hours of ABA therapy plus occupational therapy. This represents a significant therapeutic load for a two-year-old patient. Increasing the frequency of speech therapy to three hours per week is unlikely to result in substantially greater gains than those achieved with two hours of speech therapy per week and could result in treatment fatigue in this patient given her young age. Two hours per week of speech therapy as authorized by the Health Plan is medically reasonable and appropriate in this setting. As such, the medical necessity of three hours per week of speech therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for transperineal placement of a hydrogel SpaceOAR. The enrollee underwent a prostate biopsy due to an elevated prostate specific antigen; it showed high-risk prostate cancer. A computed tomography scan was negative for metastasis. The enrollee elected radiation therapy, with placement of the hydrogel SpaceOAR in order to decrease the risk of rectal injury during radiation. A study reports hydrogel placement has a success rate of 99 percent. There were no device-related adverse events, rectal perforations, serious bleeding, or infections within either the treated or control group. Literature shows the hydrogel spacer application is a relatively safe procedure; well tolerated and with a high success rate. Spacer application significantly reduces radiation dosage and results in long-term reductions in rectal toxicity, as well as improvements in bowel, urinary, and sexual quality of life.Final Result: Two of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 75-year-old male enrollee has requested continued physical therapy, at a frequency of once per week for eight weeks for treatment of his cervical radiculitis. Findings:  The physician reviewer found that this patient has multilevel cervical spondylosis with nerve root compression. He has responded well to conservative management with physical therapy but remains symptomatic. Manual therapy is considered an effective treatment for patients with neck pain. His treating physician has recommended a limited course of additional physical therapy to address his residual pain and impairments. The physical therapy notes have identified specific impairments, defined a specific treatment plan, and established reasonable therapeutic goals. The patient continues to require skilled physical therapy and is not at the point where an independent home exercise program alone would allow for a similar outcome.  All told, continued physical therapy, at a frequency of once per week for eight weeks, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary  An enrollee has requested authorization and coverage for Prolastin-C infusion augmentation therapy. Findings:  The physician reviewer found that: The use Prolastin-C infusion in this patient is not consistent with the U.S. Food and Drug Administration (FDA) approved indications. The records indicate this patient has been treated with Prolastin-C infusion for augmentation treatment for alpha-1 antitrypsin deficiency. However, the approved indications include patients who are homozygous and have an alpha-1 antitrypsin level less than 11. This patient is heterozygous, has an alpha-1 antitrypsin level of 57.4, and the phenotype is MZ. There is no objective documentation that the use of augmentation therapy for patients who are heterozygous improves the long-term health outcomes. All told, the requested Prolastin-C augmentation therapy in this patient is not medically necessary.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 internal medicine with sub-specialty certification in pulmonary 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 an enrollee has requested Synagis for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that according to Jung `The morbidity caused by respiratory syncytial virus (RSV) infection in children with congenital heart disease (CHD) correlates with the severity of the underlying cardiac disease, represented by the degree of compromise of the baseline functional status in cardiopulmonary system, pulmonary flow/ventilation mechanics, degree of cyanosis, level of pulmonary hypertension and extent of ventilation/perfusion mismatch.`  This patient has complicated and severe congenital heart disease, placing her at continued risk of contracting severe RSV disease despite her age.  Despite not meeting American Academy of Pediatrics guidelines, because of the complexity of this patients congenital heart disease and the significant risk of morbidity and mortality with RSV infection, Synagis is medically necessary and appropriate for this patient for the duration of the RSV season.  Final Result:  The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition.  Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  The reviewer is board certified in pediatrics and pediatric critical care 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Olysio 150 mg and Sovaldi 400 mg with ribavirin 600 mg for duration of 24 weeks. 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), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. This patients records do not document the presence of cirrhosis, and no other reason for urgent re-treatment compatible with the guidelines is provided. For these reasons, the requested treatment with Olysio 150 mg and Sovaldi 400 mg with ribavirin 600 mg for duration of 24 weeks is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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 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 46-year-old female enrollee has requested a colonoscopy for an evaluation of her colorectal condition. Findings:  The physician reviewer found that according to the American Gastroenterological Association Guidelines related to colorectal cancer screening and surveillance, patients with a first-degree relative (parent, sibling, or child) with colon cancer or adenomatous polyps diagnosed prior to 60 years, or two first-degree relatives diagnosed with colorectal cancer at any age, should be advised to have screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosed person in the family, whichever comes first, with repeat exams every five years.  Patients with a first-degree relative with colon cancer or adenomatous polyps diagnosed prior to or at age 60 years or two second-degree relatives with colorectal cancer should be advised to be screened as average-risk persons, but beginning at age 40 years.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Gammagard home infusions. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain. The records provided for review document that this patients symptoms and history are consistent with small fiber polyneuropathy. Further work-up has been suggestive of an autoimmune etiology. Based on the medical literature, the requested Gammagard infusions are medically necessary for treatment of this patient. Moreover, administering infusions at home is within the standard of care. Given these findings, the requested Gammagard home infusions are 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 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 patient has requested authorization and coverage for intravenous (IV) Reclast 5 mg.  Findings:  The physician reviewer found that based on the available documentation, this patient has osteopenia on dual energy x-ray absorptiometry (DEXA) scan and her fracture risk score is 6.5%. Previous therapy has included IV zoledronic acid, which the provider noted the patient was able to tolerate. The patients clinical presentation is complicated by inflammatory bowel disease (IBD) and erosive gastritis. The medical records demonstrate gastrointestinal issues that prevent her from tolerating oral bisphosphonates. However, there is no history of contraindication to IV bisphosphonates or of chronic kidney disease. Given the patients presentation, the current National Osteoporosis Foundation (NOF) support treatment with IV bisphosphonates. Reclast is the preferred IV bisphosphonate for use when oral bisphosphonates are not tolerated, as in this case. Overall, the records indicate a need for bisphosphonate therapy via IV route. For these reasons, the requested IV Reclast 5 mg 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 patient is a 64-year-old morbidly obese woman who is seeking panniculectomy for a large pendulous panniculus. She was seen and evaluated by her dermatologist and her plastic surgeon in June 2004 for her pannus. After examining the patient, the plastic surgeon documented the discussion of the patients morbid obesity and the many comorbidities that presently put the patient at risk for any operative procedure. The patient wishes to undergo a panniculectomy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically indicated.The patient is an elderly and morbidly obese woman with severe comorbidities of diabetes, hypertension, hypothyroidism, hyperlipidemia, and osteoarthritis. The complaint of circulation decreasing to her lower extremities is not noted to be present in the submitted notes but could be secondary to another comorbid condition, i.e., peripheral vascular disease. The submitted photographs and clinical notes reveal no evidence of untreatable intertrigo or rash. The patients providers recommendation to treat the patients morbid obesity is medically reasonable and appropriate. A panniculectomy is not medically indicated at this time. 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: Urgent Care
Decision: Upheld

A 34-year-old female enrollee has requested an emergency room visit for the treatment of her head and neck pain. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with appear to be of a chronic and intermittent nature. She reported having similar headaches many times in the past and did not report any worsening symptoms. There is no evidence of a life-threatening cause of her headache, such as meningitis or subarachnoid hemorrhage. It is not reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral occipital nerve blocks. Findings:  The physician reviewer found that patients provider reports a history of occipital based headaches with physical examination confirming tenderness over the occipital area reproducing the headaches. The patient has been treated with conservative care including chiropractic care, heat, physical therapy, and medication management without adequate improvement in her headaches. There is adequate evidence in the peer-reviewed medical literature to support treatment with occipital nerve blocks for this patients occipital neuralgia given the failure of symptomatic control with standard available therapies. A review by Pan and colleagues on the treatment of patients with occipital neuralgia found that, The occipital nerve block is considered the first-line in a minimally invasive intervention, but the duration of relief may be short-term. Barmherzig and colleagues evaluated the current evidence and recommendations for the diagnosis and management of occipital neuralgia and noted that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. The authors concluded that, Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Given these findings, the requested bilateral occipital nerve blocks 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 requested services 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 requested services 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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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.