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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program 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.  Prior to dates of service in question, there was no indication that the patient was an immediate risk of harm to herself or to others. The patient completed the detoxification process and did not have severe acute withdrawal symptoms.  She was compliant with medications and treatment. The patient was highly engaged in group therapy sessions, and she was medically stable.  The patient was motivated for change.  She has a history of a five-year period of sobriety which she achieved through attending community Alcoholics Anonymous meetings. The patient had a supportive family that encouraged sobriety.  Although the patient continued to require treatment for her alcohol use disorder, this could have been done in a less restrictive setting such as an intensive outpatient program level of care.  All told, partial hospitalization program services for the remainder of 30 days were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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: An enrollee has requested authorization and coverage for guselkumab (Tremfya). The submitted documentation does not support the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids, methotrexate, and Humira. However, there is no documentation that the patient has tried and failed, or has a contraindication to the Health Plans formulary alternatives including Enbrel and Remicade. Therefore, guselkumab (Tremfya) is not medically necessary 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 75-year-old male enrollee has requested a minimally invasive lumbar decompression (CPT 0275T) for treatment of his spinal stenosis.  Findings:  The physician reviewer found that the concept of minimally invasive spinal surgery embodies the goal of achieving clinical outcomes comparable to those of conventional open surgery, while minimizing the risk of iatrogenic injury that may be incurred during the exposure process. The development of microscopy, laser technology, endoscopy, and video and image guidance systems provided the foundation on which minimally invasive spinal surgery is based. Minimally invasive treatments have been undertaken in all areas of the spinal axis since the 20th century. Cervical disc disease has been treated using chemonucleolysis, percutaneous discectomy, laser discectomy, intradiscal thermoablation, and minimally invasive microdiscectomy techniques. However, until better scientific evidence is available, minimally invasive lumbar decompression is still considered a research technique.  Minimally invasive lumbar decompression remains unproven, as there is no established clinical efficacy present in the available literature. In sum, the requested procedure is not considered to be standard treatment within the medical community and is not medically necessary in the case of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy and 17 hours per month of supervision provided for treatment of the autism. Findings: The physician reviewer found that the peer-reviewed literature demonstrates the correlation between treatment outcomes and treatment intensity for children with autism. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. The patient continues to have issues with noncompliance, tantrum behaviors, elopement, screaming, non-response, and vocal stereotypy. Furthermore, the patients maladaptive behaviors have increased over the last six months. Final Result: The reviewer determined that the services at issue were and 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 with sub-specialty certification in developmental-behavioral pediatrics 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 61-year-old female enrollee has requested facet joint injections and future facet joint injections for treatment of her pain. Findings:  The physician reviewer found that based on review of the available records, on initiation of GH therapy, the patient met criteria for GH deficiency, as his height was more than 2 standard deviations below normal and results of provocative GH testing showed a peak GH response less than 10 ng/mL. Currently, the patient is in the midst of his pubertal growth spurt. Despite the fact that the patient has already attained a height that is within the normal range for a fully grown adult, it would be inappropriate to withdraw GH therapy in this GH deficient adolescent while he is in the midst of his pubertal growth spurt. As GH is important for other factors besides growth, such as deposition of muscle mass, bone density, and cardiovascular health, GH is medically necessary until the patients growth velocity slows to less than 2 cm per year and/or epiphyses are closed on bone age X-ray, at which point his status should be reassessed in the context of adult standards for determining medical necessity of GH therapy. Continuation of GH therapy is therefore medically necessary for treatment of this patients medical condition for one year with reevaluation at that time.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested acute inpatient and residential psychiatric services for the treatment of his bipolar disorder. Findings:  The physician reviewer found that he had, had previous acute psychiatric hospitalizations and was receiving pharmacotherapy. His acute stay also appears to have been extended for several days while waiting for residential placement at his facility of choice. A less intensive level of care would have been more appropriate than acute inpatient care. The clinical evidence indicates he was still psychiatrically ill at that time and medication adjustments were on going. In addition, once the final regimen of Lamictal, Neurontin, Klonopin, and Thorazine was established, close supervision for a reasonable length of time was warranted. The transition to residential treatment was clinically reasonable and coverage should be provided.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her lumbosacral radiculitis. Findings:  The physician reviewer found that the FDA approved indications for Lyrica are limited, it is commonly prescribed for neuropathic pain when more conservative treatment strategies have proven to be ineffective, as in this case.
Appeal type: Medical Necessity
Decision: Upheld

The enrollees parent is requesting authorization and coverage for residential treatment center (RTC) services. The enrollee has major depressive disorder and anxiety. She entered the residential treatment center level of care. The goals of the program are to provide treatment for presenting issues, to provide clinical assessment, and to assist the family in creating an aftercare plan to support long-term change. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollee is at a low risk of harm and has a support system in place. The enrollee is able to develop a trusting, positive relationship care providers. The enrollees composite LOCUS score correlates with Level II; however, due to a score on Dimension V, the recommended level of care is Level III, high intensity, community-based care.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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a seven-year-old female enrollee has requested continuous glucose monitoring device for the treatment of the enrollees type I diabetes mellitus. Findings:  Two physician reviewers found that continuous glucose monitoring devices are not experimental or investigational when used appropriately, on a periodic basis, under the auspices of an endocrinologist. In the case of patients with type I diabetes who have inadequate glycemic control despite frequent self-monitoring of their blood sugars, a CGMS becomes a necessary adjunct to standard care. Poor control with frequent hyperglycemia or recurrent episodes of severe hypoglycemia, in spite of frequent self-monitoring of blood glucose, requires the use of a CGMS device to initiate changes in food intake or insulin and thereby optimize blood sugar control.
Appeal type: Medical Necessity
Decision: Overturned

Standard Review: A transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollees gender dysphoria.  Credentials/Qualifications: The reviewer is board certified in plastic 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. Nature of Statutory Criteria/Case Summary: Based on the documentation provided, the patient has documented gender dysphoria and is in the process of transitioning to the male gender. According to the records provided, this patient has lived as a male for many years. While he has been undergoing prescribed hormonal therapy for more than 3 years, he has evidence of breast development that is abnormal for a male gender. The records provided also indicate that he continues to have gender dysphoria related to breast development. The records note that he binds his breasts regularly.  In addition, his treating providers noted that this patient is ready for a breast mastectomy and support his request for consultation. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male should be the goal. All told, there is sufficient documentation to maintain next steps towards this patients transition to the male gender. Therefore, a consultation with a plastic surgeon regarding a bilateral mastectomy is medically necessary for the evaluation of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 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. 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 or Zepatier 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Therefore, Zepatier is medically necessary 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 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 Harvoni 90-400 mg tablet for treatment of the enrollees chronic hepatitis C virus 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 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 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the patient should be treated with Harvoni 90-400 mg tablet for 12 weeks, which is supported as 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 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: The patient has requested authorization and coverage for Dupixent solution pen-injector (inject 300 mg pen subcutaneously every other week). The U.S Food and Drug Administration (FDA) approves the use of Dupixent for the treatment of adult patients with moderate-to-severe atopic dermatitis. While topical tacrolimus may be used to treat moderate-to-severe atopic dermatitis, and topical pimecrolimus may be used to treat mild-to-moderate dermatitis, the records noted that topical medications were challenging for the patient to apply and keep on his hands. Deleuran and colleagues report that the safety and efficacy profile from an ongoing, multicenter, open-label extension study supports the role of dupilumab as continuous long-term treatment for patients with moderate-to-severe atopic dermatitis. While the American Academy of Dermatology (AAD) notes that systemic medications such as methotrexate, azathioprine, corticosteroids, mycophenolate, and cyclosporine are used more commonly for the treatment of refractory moderate-to-severe atopic dermatitis not responsive to topical medications, these guidelines were published in 2014, prior to the availability of Dupixent. Methotrexate, azathioprine, corticosteroids, mycophenolate, and cyclosporine cannot be used chronically because of severe potential side effects and may require routing laboratory monitoring. In this case, given that current medical literature supports the use of Dupixent as effective and with fewer side effects than with other systemic medications used to treat moderate-to-severe atopic dermatitis, the requested medication is medically indicated. Therefore, Dupixent solution pen-injector (inject 300 mg pen subcutaneously every other week) 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested for breast augmentation for treatment of her polycystic ovaries. Findings:  The physician reviewer found that polycystic ovaries are due to an imbalance in female sex hormone production by the body.  Although this patient may have polycystic ovaries, she does have breast tissue in her breasts and normal nipple areola structures.The requested surgery is not being performed to improve function or create a normal appearance, as she already has a normal appearance.  All told, the requested breast augmentation is not reconstructive in nature and is not medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) utilizing the EsophyX device. Appropriate patient selection is critical prior to performance of anti-reflux procedures. In prelude to surgical intervention for GERD, one study noted that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. The study noted that it is important to document the presence of abnormal distal esophageal acid exposure, to outweigh the potential side effects of fundoplication. This patients records document that she has undergone some of the recommended preoperative evaluation for treatment of her diagnosis of GERD. However, the medical records document does not support that the patient is medically refractory to acid blocker medications nor support the presence of advanced GERD or endoscopic evidence of esophagitis. Moreover, TIF has not been evaluated for use in patients with complaints of dysphagia in the form of globus sensation as in this patients case. All told, the requested TIF utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF utilizing the EsophyX device is 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 requested TIF utilizing the EsophyX device is 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

A 63-year-old female enrollee requested intra-fraction localization and tracking of target or PT motion during delivery of radiation therapy (CPT code 0197T) and unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999) for treatment of her cancer in the left breast.   Findings:  Two physician reviewers found that use of intra-fraction localization and tracking of target or PT motion during delivery of radiation therapy (CPT code 0197T) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. However, the records do not include a request by the radiation oncologist for the requested unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999). Further, the providers notes did not recommend this diagnostic procedure. Moreover there is a lack of a clinical indication for the requested unlisted miscellaneous procedure, diagnostic nuclear medicine (CPT code 78999). Therefore, the requested diagnostic procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  A portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.