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

Nature of Statutory Criteria/Case Summary: The parent of a four-year-old enrollee has requested admittance into a childrens hospital intensive multidisciplinary feeding program for treatment of the enrollees feeding problems. Findings: The physician reviewer found that this patient is gastrostomy tube dependent and has been in outpatient therapy without much progression. He has not shown a failure to thrive and does not have electrolyte abnormalities but this is because he is getting gastrostomy tube feeds. The patient is no longer progressing in outpatient therapy, so inpatient therapy may be able to get him to take foods by mouth as well as accept a larger variety of foods. The goal is to stop his gastrostomy tube, and inpatient feeding programs have been shown to be more effective than outpatient therapy sessions. All told, the requested admittance into a childrens hospital intensive multidisciplinary feeding program is supported as medically necessary for treatment of this patients feeding problems.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 pediatrics and pediatric 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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:   All three reviewers are board certified in diagnostic radiology 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: Upheld

A 21-year-old male enrollee has requested a consultation followed (if appropriate) by transcranial magnetic stimulation therapy for treatment of his major depression.  Findings:  The physician reviewer found that the data reviewed do not support the requested services in this patients case. He has been on two antidepressants concurrently, and a third antidepressant has been added. The evidence is insufficient to support transcranial magnetic stimulation in patients who have failed trials of two or more antidepressants. Additionally, there is a lack of medical literature supporting the use of transcranial magnetic stimulation in patients with comorbid Aspergers syndrome or other autism spectrum disorders. The record indicates that the patients psychiatric condition may be adversely affecting his physical health.  The Health Plan has offered electroconvulsive therapy as a treatment option, and the current medical evidence supports electroconvulsive therapy in this clinical scenario.  All told, the requested services are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the gene test (DecisionDx-Melanoma test) for malignant melanoma on her right medial breast, 0.65 mm Breslows depth and Clarks Level II. Per testing report, the DecisionDx-Melanoma class was 1 and sub-class was 1A. A Class 1A signature is associated with the lowest risk of recurrence within five years. According to the medical literature, the use of the DecisionDx-Melanoma assay panel is not currently recommended. There needs to be prospective analyses of patients who are representative of the general primary melanoma patient population focused on definitive assessment of the sensitivity and specificity of this test. Guidance on interpretation of the results of the DecisionDx-Melanoma assay is critical since a lack of understanding of test results by clinicians may prompt additional or more frequent diagnostics than needed without definitive patient benefit. There is the necessity for a much larger trial to properly utilize this testing procedure as the basis for diagnostic recommendations. The DecisionDx-Melanoma assay is not considered to offer additional benefits in patient management of melanoma. This test is not approved for melanoma testing by any other regulatory bodies for this diagnosis.  The clinical value of this test remains unclear and although there is interest in newer diagnostics, such as gene profiling, to help determine risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. There is insufficient evidence to propose routine clinical management, including decision making regarding sentinel lymph node biopsy, should be altered by the results of gene expression profiling. The use of this test has not been shown to improve health outcomes in melanoma.                                                   Final Result: Three of the three reviewers determined that the requested services were not 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees occipital neuralgia and neuritis.At issue in this case is whether the requested medication Lyrica is medically necessary for treatment of the patients medical condition.A study noted that pregabalin (Lyrica) is a very effective agent for the treatment of neuropathic pain and has a very good safety profile. The patient has trialed and failed treatment with use of tricyclic antidepressants (amitriptyline); and anti-convulsants (gabapentin); as well as topical Lidoderm. The patient has reported good pain relief with Lyrica samples provided by the physicians office. Therefore, given the failure of previous medications and proven efficacy of Lyrica in this patient, the requested medication is medically necessary.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 anesthesiology with subspecialty 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

Nature of Statutory Criteria/Case Summary:  The guardian of an enrollee has requested mental health residential treatment services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.   The patients psychiatric medications did not require a residential setting for management.  She had improved and was making progress towards emotional regulation and conflict resolution.  Per the medical records, the patient could have been treated safely and effectively at an intensive outpatient program level of care along with family therapy sessions and community-based substance abuse systems, such as a 12-step program.  All told, mental health residential treatment services were not medically indicated 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee's representative is requesting reimbursement for the proton beam radiation therapy provided for treatment of the enrollees metastatic lung cancer.Findings: The three physician reviewers found that there is currently a lack of medical literature to support that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for patients with metastatic disease. Standard treatment with photon radiation is associated with a very low risk of toxicity. Moreover, there is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the surrounding normal structures compared to standard photon techniques using intensity modulated radiation therapy. Consensus group guidelines from the National Comprehensive Cancer Network (NCCN) also do not support the use of proton therapy in this clinical setting. Based on these reasons, the proton beam radiation therapy provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The three physician reviewers are board certified in radiation 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: Overturned

The parent of a 6-year-old male enrollee has requested for additional physical and occupational therapy for treatment of the enrollees neurofibromatosis. Findings:  The physician reviewer found that the patient is has cognitive, functional, coordination, and visual deficits that all would likely benefit from PT and OT services. It is my determination that PT and OT services are medically necessary to treat this patients complicated medical condition. The requested PT and OT services do directly relate to a treatment regimen for the patients condition. While the patient does have a chronic condition, symptoms can fluctuate in severity over time and the patient can experience various manifestations of the disease at various times.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested occupational therapy and speech therapy services for treatment of the enrollees autism. Findings:  The physician reviewer found that based on the records provided, the requested speech and occupational therapy with sensory integration for this patients delays are medically necessary based on an overall evaluation of the literature, including a positive analysis from Myers and colleagues. Key to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease such as the pathogenetic process that gave rise to this patients speech and language delays, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, sensory integration-based occupational therapy and speech therapy for this patient are necessary to reduce the physical and mental effects of the patients underlying neurologic condition and to achieve maximum function in maintaining daily activities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old female with previously diagnosed polysubstance abuse (cannabis, alcohol, and cocaine), post-traumatic stress disorder, anorexia nervosa, and bipolar disorder versus mood disorder-not otherwise specified. The patient was admitted to residential treatment on 4/30/04 due to persistent problems with mood regulation, substance abuse, recurrent self-harm and suicide attempts, defiant behavior, and caloric restriction. She has a history of severe verbal outbursts and irritability that can last from minutes to hours, requiring isolation for stabilization. She has also been overly sensitive to noise and stress. Finally, the patient has noted visual hallucinations, reportedly seeing things such as the floor moving, blood coming out of the walls, and little people approaching her. She has also periodically heard a single male voice telling her to hurt people or that she should die, though she has never directly acted on this voice. The patient noted severe and debilitating depressive episodes, very low self-esteem, feeling irritable most of the time, wildly fluctuating energy levels, markedly decreased appetite, and significant difficulties initiating and maintaining sleep. She eventually reported having been raped some two years earlier. Treatment has included a number of psychotherapies as well as medication, the latter in the form of Effexor and Seroquel, which was latter switched to Zyprexa. This switch was thought to be more effective in helping regulate the vacillation in her mood. By 7/14/04, the patient was noted to be sleeping well, with decreased tearfulness, and was able to refrain from all self-injurious behaviors, including no oral restriction. It was further noted the patient reported feeling better overall.A request has been made for continued residential psychiatric treatment services. The Health Plan has denied this request on the basis that the requested services are not medically necessary.Though there was some uncertainty about the exact sort of mood disorder the patient experienced, i.e., whether her condition was bipolar in origin, by 7/14/04 the patient had improved from the vantage points of irritability and aggressive acting out. Additionally, as of that time the patient was not suicidal and her provider believed that she was not likely to resume substance use. Based upon the records submitted, it appears that the patient could have been appropriately treated at a less intensive level of care as of 7/14/04. Therefore, I have determined that 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1a. 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. This recommendation applies to all patients, regardless of fibrosis stage. Per the guidelines, patients with extrahepatic manifestations of hepatitis C, such as those with symptomatic cryoglobulinemia as in this case, should be prioritized for treatment.  The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a 12-week course of Epclusa 400/100 mg. Findings:  The physician reviewer found that, according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival.  All told, the requested 12-week course of Epclusa 400/100 mg is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Overturned

A 32-year-old female enrollee has requested a power operated wheelchair for treatment of her ataxia. Findings:  The physician reviewer found that with regard to this patients ability to operate a manual wheelchair, she has a progressive neurodegenerative disorder that has resulted in significant disability. She has multiple severe impairments including upper extremity incoordination, lower extremity weakness, muscle spasticity, truncal ataxia, and poor endurance. She has required the use of a power wheelchair for several years now in order to safely perform her activities of daily living (ADLs) and all mobility-related activities. In fact, the majority of the patients records support her need for a power wheelchair. She is unable to ambulate and has impaired upper extremity coordination with poor endurance that would significantly limit her ability to self-propel a manual wheelchair. Therefore, after considering the information provided for review and the guidelines available in the medical literature, there is adequate documentation to justify the medical necessity of a motorized wheelchair for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old female with previously diagnosed Bipolar Disorder having entered partial hospitalization in June 2006 due to extreme anxiety, depressed mood, feelings of hopelessness, disrupted sleep, and poor concentration. Relevant stressors included a divorce from her husband, child custody issues and pending judicial hearings. She was initially seen three to four times per week and was intended to continue attending with a frequency of one to three times per week as of August 2006. Due to insurance issues it appears PHP was discontinued in September 2006. The Health Plan has denied coverage for additional PHP services on the basis that they are not medically necessary.Overall, the patient suffers from Bipolar Disorder and has had some very serious consequences of her unbridled illness. She also appears to have an excess sensitivity or perceived sensitivity to medications, which are mainstay treatments of her illness, namely Depakote and Lamictal. As such, it is appropriate for the patient to be tried on other medications in order to stabilize her, eg., Lithium. Based on the notes submitted, she appears to have still been rather depressed and anxious by the end of PHP in September 2006. In light of the continued social stressors the patient is experiencing, she meets authorization for additional PHP services. She should receive PHP services three times a week for an additional four weeks with re-evaluation by her psychiatrist at the end of the four-week period.Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.