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

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus. Findings:  Two physician reviewers found that current treatment guidelines by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) emphasize that those patients most likely to benefit from viral eradication should be treated with a direct-acting antiviral (DAA) hepatitis C drug. Individuals with advanced fibrosis and/or severe disease activity would benefit the most such as those with extrahepatic manifestations such as cryoglobulinemia, which this patient is not known to have. In this clinical setting, following this patient by yearly assessments for fibrosis using non-invasive testing is appropriate. Therefore, the requested medication is 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 authorization and coverage for a second magnetic resonance imaging (MRI) of the facial area. This patient has a mass on her face that is producing facial deformity. The mass has increased in size and two biopsies were different pathologically. It is well known that liposarcoma may be difficult to diagnose on punch biopsy as this type of tumor may be eccentric and non-uniform. A high resolution contrast enhanced MRI with appropriate marking of the skin superficial to the mass may provide critical diagnostic information. The MRI may help target an area for biopsy, which in turn may provide a diagnosis suitable for treatment. Pathologic analysis and imaging findings thus far have not yielded a confirmed diagnosis, nor have they pinpointed a target for directed biopsy. The patient has symptoms which are progressive leading to facial deformity. Thus, the requested repeat MRI is supported as medically necessary for evaluation of this patients medical condition. 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 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

An enrollee has requested reimbursement and authorization and coverage for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria is a validated placement tool. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. In this case, using the ASAM 3.5 criteria, the patient meets all six dimensions for level 3.5 residential treatment center (RTC) level of services. Accordingly, residential treatment center (RTC) services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patient's 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. The records indicate that the patient was admitted to the RTC due to some oppositional behaviors, anxiety symptoms, and difficulties with social interaction. The progress notes did not describe any significant mood symptoms. The records suggest the majority of the patients functional impairment was due to his autism spectrum disorder and difficulties with social interaction. The progress notes do not reflect any occurrence of any intensive family therapy prior to admission. While at the treatment center, the patient was engaging in cognitive behavioral therapy. The progress notes did not indicate that there were any issues with substance use, history of suicidal ideation or thoughts or suicide attempts, and he was not noted to have aggressive behaviors or self harm behaviors during his stay. The patient denied any serious depression or anhedonia during his stay. According to the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient was considered a low risk of harm as evidenced by the the medical records documenting a lack of active suicidal ideation and no history of suicidal ideation or attempts. During his stay, he did not exhibit any aggressive behaviors. Due to his lack of severe symptoms and dangerous behaviors, treatment in a less restrictive care setting was appropriate, especially as related to family therapy and cognitive behavioral therapy for his anxiety symptoms. Due to the patients mild symptoms and lack of evidence to support failure of less restrictive treatment, the RTC services were not medically necessary for treatment of this patients behavioral health issues. 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 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: Overturned

The parent of a 16-year-old male enrollee has requested  inpatient acute psychiatric treatment with evaluation by a forensic psychologist for treatment of the enrollees anxiety, major depression, and attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that the patient does have a formidable symptom complex, the etiology of which has been difficult to determine. The aggression is of particular concern since it is considered to be a relatively stable trait, and aggression in childhood often predicts continuation or even escalation of behavior problems over time (Newcorn, et al). Considering the patients refractivity to comprehensive treatment and the recommendation from the psychological consultation on the date specified, evaluation by an outpatient forensic psychologist is medically necessary. The potential benefits of a consultation with a forensic psychologist would include a definitive assessment of dangerousness, an additional diagnostic opinion, and clinical recommendations for the treatment plan. For these reasons, the requested evaluation by a forensic psychologist is supported as medically necessary while the resumption of inpatient acute psychiatric treatment is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech delay and lisp. Findings:  The physician reviewer found that according to the medical literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior. In particular, speech sound disorder not only greatly reduces intelligibility it has also been associated with later reading disability (Smith, et al). Specifically, the authors noted that, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The concern is that, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age. They may have difficulty reading in grade school, exhibit poor reading skills at age 7 or 8, and have difficulty with written language, in particular. In addition to persistent speech- and language-related underachievement, language-delayed children have also shown more behavior problems and impaired psychosocial adjustment (Nelson, et al). It is clear that speech disorders must be taken very seriously, and intervention should be timely and comprehensive. Given these factors, the speech therapy services provided to this patient have been proven to be medically necessary for management of his speech delay and lisp.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male who was placed in an alternative classroom setting due to his psychiatric and behavioral problems. He reports abusing methamphetamine and marijuana as well as obtaining money to supply him with drugs by prostitution. There is a possible history of sexual abuse in the past. Several months ago the patient was placed on a 5150 hold because of his acute intoxication and threats to use a gun on himself. He was hospitalized and residential treatment was recommended. The patient was discharged from the hospital but did not enter residential treatment. His discharge medications included an antidepressant. His psychotic ideation cleared when he was withdrawn from the methaphetamines. A request has been made for authorization and coverage for residential treatment services. The Health Plan indicates the patient does not require 24-hour supervised care and therefore the requested services are not medically necessary. Though there is a strong suggestion of a dual diagnosis in this case (major depression with chemical dependency) it is difficult to sort out if the depressive symptoms are secondary to the methamphetamine abuse or instead preceded the use of amphetamines. The customary treatment for patients such as this patient is to initiate chemical dependency treatment while monitoring the level of depression and compliance with the patients prescribed medications. There is no evidence the patient has tried and failed any community-based treatment. Furthermore, the Health Plan has offered partial hospitalization services for the patients continuing psychiatric needs. Alternative treatment options of a chemical dependency program and a partial hospitalization program with individual and family therapy are appropriate for treatment of the patients chemical dependency and psychiatric issues. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested 10 hours of psychotherapy sessions per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that based upon the information provided, the disputed services consist of behavior modification therapy and are mislabeled and miscoded as psychotherapy. In regard to behavior modification therapy, there is limited evidence concerning the efficacy of behavior modification therapy on autistic features, particularly stereotypical repetitive behaviors (Patterson et al.). Such behavior modification techniques remain unproven in terms of improving communication, social skills, and overall management of children with autism spectrum disorder (Vismara et al.). That said, in addition to autism, the patient has diagnoses of obsessive compulsive behavior and anxiety. While the disputed therapy is not within community standards for treatment of autism, the therapy is appropriate for treatment of anxiety and obsessive compulsive behavior. Based on the documentation provided, this patient has made some gains with his present program. The past services were medically appropriate and necessary for treatment of the patients condition. With regard to future therapy, the patient continues to have deficits that are likely to benefit from additional therapy. However, 10 hours per week of therapy is excessive. Continuation of the disputed therapy is medically necessary for this patient at a frequency of two one-hour sessions per week with reevaluation after six months.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Dupixent. The enrollee has eczematous dermatitis affecting 20% of his body surface area (BSA).  Currently he is using betamethasone dipropionate 0.05% ointment and over-the-counter Lamisil cream on his feet. At an office visit, the enrollees rash had recently spread to his trunk, legs, and arms.  It itched all day and worsened after narrowband ultraviolet B (nbUVB) rays.  The enrollee was not a candidate for methotrexate. It was recommended the enrollee stop nbUVB, continue clobetasol 0.05% ointment and start Dupixent (dupilumab). The dermatologist indicates the enrollee has tried and failed clobetasol, a super-high potency topical corticosteroid, and other topical corticosteroids and does not believe further use of topical medications as a sole treatment modality are an appropriate choice because of the extensive BSA affected. A calcineurin inhibitor has not been trialed due to the limited efficacy of the medications and the large surface area that would need to be covered by the medications. Topical calcineurin inhibitors are further not a reasonable option given the common side effects of burning, redness and irritation associated with their applications. The enrollees physician provides a supporting argument as to why the enrollees systemic flare is not ideal for topical treatment; however, there is insufficient evidence in the record that other systemic option treatments, such as oral cyclosporine or a short-course of an oral steroid, were ruled out or trialed before considering biologic treatment with Dupixent. There is no documentation the patient has tried any oral, immunosuppressive treatment in the past to control his medical condition. Systemic therapies include cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate. The usual systemic treatment for atopic dermatitis has been cyclosporine due to its rapid onset of action, with significant improvement in disease severity seen within a few weeks. Current literature supports the use of biologics for long-term management in patients with moderate to severe atopic dermatitis. The record in this case provides insufficient evidence of whether this patient has moderate-to-severe or mild-to-moderate atopic dermatitis. The severity grading of the patients medical condition is not documented.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys spray for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not document that the patient has exhausted non-opioid treatment options.  The clinical notes indicate that the providers long-term plan for treating tolerance is not clear.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Subsys spray is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested for occupational therapy, one-hour sessions, twice per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that occupational therapy is a well accepted modality for patients with autism. In order to establish the need for occupational therapy in a particular patient, there must be objective documentation of functional deficits that require the expertise of a skilled therapist. In the case of this patient, the submitted occupational therapy reports primarily document sensory issues without describing the effect they have on the patients functional skills.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for behavior analysis services and applied behavioral analysis services.In this case, the patient has diagnoses of anxiety, attention deficit hyperactivity disorder (ADHD), and sensory processing disorder, but does not have a diagnosis of autism. The number of hours in the patient's treatment request is also very low, which is better suited to an outpatient program. As established above, outpatient therapies such as family based CBT therapy, utilize an outpatient model that is more conducive to the severity of problem behavior identified. Given the rates of behavior on the functional behavior assessment were low (.17/hr meltdown and 1.7/hr protests) and the family is only requesting parent training, the case can also be made that this is not a significant problem that warrants ABA intervention. Under these circumstances, the behavior analysis services in issue, and the requested applied behavioral analysis services, were not, and are not, medically necessary for the patients medical condition. Final Result: The reviewer determined that the services in issue and requested services were not, and are not, medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed psychologist, and board certified behavior analyst, 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 40-year-old female enrollee has requested a hospital bed for treatment of her multiple medical problems.  Findings:  The physician reviewer found that there is no documented medical necessity for the hospital bed at issue. The patient is not bed bound and her legs can be elevated in a regular bed. She has chronic back pain without objective evidence of nerve impingement. There is no evidence in the medical literature that indicates a hospital bed is necessary for the treatment of this patients condition, nor is it the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old woman with chronic obstructive pulmonary disease and cardiomyopathy.  In February 2001, a pacemaker was implanted for symptomatic second-degree atrioventricular block. The patient underwent a screening mammogram in June 2003. The patient reports the procedure caused her pacemaker to dislodge. In February 2004, the patient reported her pacemaker had moved. A chest x-ray confirmed the pacemaker was lower in the chest than previous studies. The pacemaker was revised and a new pacemaker implanted. The patient is concerned a mammogram will dislodge her pacemaker. Therefore, she has requested authorization and coverage for a breast ultrasound as an alternative to a mammogram. The Health Plan has denied authorization and coverage for the requested ultrasound on the basis that it is not medically necessary for evaluation of the patients medical condition.The Health Plans denial should be upheld. Pacemaker dislodgement is not a recognized complication of mammography. A pacemaker is normally attached to the pectoral muscle in the deltopectoral groove. This location is cephalad and dorsal to the breast. Compression of the breast should not affect the pacemaker. Therefore, I have determined that the requested ultrasound is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name Xanax and Zoloft for treatment of the enrollees behavioral health issues. Findings: The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), drug products are considered pharmaceutical equivalents if they contain the same active ingredient(s), are of the same dosage form, route of administration and are formulated to contain the same amount of active ingredient, and to meet the same or compendial or other applicable standards including strength, quality, purity, and identity. The drug products may differ in characteristics such as shape, scoring configuration, release mechanisms, packaging, excipients such as colors, flavors, preservatives, expiration time, and, within certain limits, labeling. Drug products are considered to be therapeutic equivalents only if they are pharmaceutical equivalents for which bioequivalence has been demonstrated, and they can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling. Both Xanax and Zoloft are found in the FDA Orange Book and are listed as alprazolam and sertraline, respectively. Thus, the generic forms of these medications would be no different in bioavailability and efficacy than the brand versions. The provider in this case noted the patients recent decompensation does not coincide with a switch from brand to generic, as the patient has been on this same generic version of sertraline and alprazolam for several years. From pharmacy records provided, it does not appear that different manufacturers were used for either of these generic medications. In addition, the worsening of the patients condition, either situational in nature or otherwise, was not described. Final Result: The reviewer determined that the requested medications 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.