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

The parent of an 8-year-old male enrollee has requested applied behavioral analysis (ABA) at a frequency of up to 15 hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. This patient was initially diagnosed as autistic at nearly 3 years of age. Subsequently, he has been the recipient of ABA services since that time to the present. This patient has been referred for ABA therapy by his school district in 2012 and by his pediatrician in the same year. Most neurologists and pediatricians recommend ABA therapy as the standard of care as ABA therapy has a well-documented record of substantially improving motor, verbal, and social interactive skills in autistic children. According to Myers and Johnson, The effectiveness of ABA-based intervention in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. In addition, according to Brosnan and Healy, ABA therapy is highly effective in reducing or eliminating aggressive behavior across a range of ages and degrees of developmental disabilities which is pertinent in treating the aggressions reported in this patient. Finally, in the article by Virues-Ortega, the author reports that long-term comprehensive ABA intervention leads to positive, medium to large effects in terms of intellectual function, language development, acquisition of social skills, acquisition of daily living skills and social functioning in a child with autism. For the reasons listed above, the requested ABA therapy at a frequency of 15 hours per week is medically necessary for this patient
Appeal type: Urgent Care
Decision: Upheld

A 31-year-old male enrollee requested medical services on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention. In this case, the patient presented for an office visit with a neurosurgeon after previously have been seen in the ED with an acute episode of neck pain and left upper extremity pain and diagnosed with a radiculitis.  At that time of the neurosurgeon appointment, his pain had significantly decreased. Moreover, the neurosurgeon told him that surgery was not emergent and could be planned. In addition, the ED notes that the need for surgery was not emergent given that his strength is nearly intact. Thus, the neurosurgeon office visit did not need to be provided on an emergent basis and surgery was also not emergent. In addition, this patients symptoms were not sudden or acute in onset that would lead a prudent layperson to believe their health to be in imminent danger. Finally, there was no sudden deterioration in his physical condition to justify immediate evaluation or treatment on the date in dispute. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested coverage for outpatient care at the frequency of 5 times per week for a past four-week period  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.   Findings:  The physician reviewer found that based on review of the available records, the provider states that the patient entered psychiatric crisis and subsequently required an increased frequency of outpatient sessions. The clinical notes do support the need for increased frequency of outpatient sessions for this patient during the period under review as recommended by the American Psychiatric Association (APA). However, there is inadequate justification to establish the medical necessity for all of the of outpatient treatment sessions provided. Therefore, as well as the sessions approved by the Health Plan, one additional session per week during the period under review was medically reasonable in order to safely manage this patients condition, and once per week thereafter through the end of the requested timeframe.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services. Overall the progress notes reflected repetitive concern over the patients relationship with boys and this appeared to be the main treatment focus. Residential treatment for adults is evidence based for reduction of serious psychiatric symptoms that are typically thought to be reversible in nature. The patient did not display serious psychiatric symptoms but rather interpersonal issues that could have been treated in a less restrictive setting. A large portion of the patients functional impairment appeared due to her borderline personality disorder traits. This is referenced by her fear of abandonment, affective instability, feelings of hopelessness and intense relationships. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for the patient.  Applying the Level of Care Utilization System (LOCUS), the RTC services provided to this patient were not and are not medically necessary. The patient has been at low risk of harm (score 2) due to a lack of current suicidal ideation. The patient has demonstrated moderate functional impairment (score 3) with overall fair functional level in school and with same sex peers. The patients co-morbidities are stable (score 2), and her recovery environment is mildly stressful (score 2). The patient has a supportive recovery environment (score 2), and limited response to prior treatment (score 3). The patient has been engaged and cooperative in treatment (score 2). This gives the patients presentation a composite score of 16, which correlates with high intensity community based services, such as intensive outpatient program (IOP) treatment. Accordingly, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dovato 50-300mg tablets.Van Wyk and colleagues state that Dovato has been shown in multiple clinical trials to achieve and maintain HIV viral suppression as effectively as three drug regimens such as Triumeq with less toxicity and adverse events. Dovato does not contain abacavir, which is associated with increased risk of stroke or myocardial infarction. According to U.S. Department of Health and Human Services (DHSS) guidelines for antiretroviral treatment in HIV, Dovato is recommended as a preferred regimen and Triumeq is not a preferred agent. Dovato is FDA indicated for both treatment naive starting treatment and treatment experienced HIV patients switching from their current three drug regimens. In this case, the patient has asymptomatic HIV disease, and his condition has been undetectable for several years on his current regimen of Triumeq. The patients provider has indicated that there is concern with the potential effects of long term highly active antiretroviral therapy (HAART) medication on the patients kidneys and liver. Given the effectiveness of Dovato as a viral suppressant, the patients provider has suggested replacing the more toxic abacavir with Dovato to maintain control of the patients viral condition while lessening the overall strain on the patients body. Under these circumstances, the requested medication, Dovato 50-300mg tablets, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in infectious disease, 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 monitored anesthesia care for her colonoscopy and esophagogastroduodenoscopy.  Findings: The physician reviewer found that there is no documentation of clinical findings that would support the need for monitored anesthesia care. The patient has a low (ASA) preoperative physical status classification score, which indicates low pre-operative risk. There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score, the requested monitored anesthesia care was not medically necessary during the patients colonoscopy and esophagogastroduodenoscopy. Therefore, the Health Plans denial for the monitored anesthesia care services at issue should be upheld.Final Result: The reviewer determined that the monitored anesthesia care at issue was not medically necessary during the patients colonoscopy and esophagogastroduodenoscopy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology 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

A 59-year-old female enrollee requested posterior tibial nerve stimulation (PTNS for medical treatment of the enrollees overactive bladder.  Findings:  Two physician reviewers found that PTNS treatments were not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the long-term efficacy of PTNS compared to standard therapies, both medical and interventional. Also, the patients confounding conditions of uterine prolapse requiring pessary, depression, overweight, antihistamine use and Ambien use do not make it possible to assess the efficacy of PTNS in isolation amongst this constellation of potential contributors to the outcome of therapy. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 13-year-old female enrollee has Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  Three physician reviewers found that given the predicted adult height estimate from the information provided, this patient would not qualify for GH therapy on the basis of idiopathic short stature according to the Food and Drug Administration (FDA) guidelines of July 2003. Moreover, the scientific data do not support the use of GH therapy in combination with gonadotropin-releasing hormone agonist (GnRH) therapy, as utilized for management of this patients condition. While some studies report positive results with this combination therapy, the patient numbers were small and the outcomes were deemed insignificant. For these reasons, the therapy remains investigational for management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left heart cardiac catheterization and heart artery ventricle angiography. The records provided for review document that this patient has several risk factors for cardiovascular disease. She has typical and atypical chest pain symptoms and nuclear stress findings reported as positive for anterior ischemia. She was started on medical therapy without substantial improvement in her symptoms. She has described exertional and rest symptoms as well as medication side effects limiting treatment options. This patient meets the American Heart Association (AHA) and American College of Cardiology Foundation (ACCF) appropriate use criteria for cardiac catheterization and coronary angiography as an intermediate risk patient with persistent and life-limiting symptoms despite medical therapy. For these reasons, the requested left heart cardiac catheterization and heart artery ventricle angiography is medically necessary for 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 internal medicine with subspecialty certification in cardiovascular disease 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 patient is a 15-year-old male who has been treated with the aromatase inhibitor, Letrozole, to extend his growth period and began treatment with growth hormone therapy in November 2005 under the care of a pediatric endocrinologist. For the three months prior to the initiation of growth hormone therapy, he had grown a modest 1cm for an annual growth rate of 4cm.  The patient grew 1.6cm over the first 4 months of GH therapy for an annualized growth rate of 4.8cm. His height in February 2006 was 161.6cm (63.6). Previous testing indicated that the patient had normal IGF-1 and thyroid hormone levels and his most recent bone age of 16 years indicates that his growth period is nearing completion. The patients father has requested reimbursement and continued authorization and coverage for growth hormone therapy. This request was denied by the Health Plan based upon a determination that growth hormone therapy was/is not medically necessary.The record indicates that the patients mother is 60 tall and his father is 69 tall, which approximates a mid-parental height of 67.  The patients height in February 2006 was 63.6 and as his growth period is nearing completion, he appears to be falling short of his target in that his projected adult height estimate is between 54.2 and 55.2. The patient does have short stature and is projected to have a short adult height. As such, the previous use of growth hormone was justified under the FDA guidelines of July 2003 for the treatment of idiopathic short stature.  The therapy should be continued until epiphyseal closure and cessation of growth.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of his medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested maternal plasma cell-free fetal DNA sequencing (Verifi Prenatal Test) for fetal aneuploidy for evaluation of her medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The American College of Obstetricians and Gynecologists (ACOG) committee opinion in regards to cell-free DNA screening for fetal aneuploidy recommends this screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Based on the clinical documentation submitted for review, this patient does not meet the criteria.  The patients history is not enough to warrant cell-free DNA screening. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal-fetal 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 patient has requested authorization and coverage for endoscopically assisted surgical expansion (EASE). The records provided for review document that this patient has mild obstructive sleep apnea (OSA). As noted in the peer-reviewed medical literature, non-surgical therapy is considered the first-line approach for patients with mild OSA. Treatment options include oral appliance therapy and continuous positive airway pressure (CPAP). For patients who cannot tolerate or fail to improve with the first-line modalities, surgery is an option. A variety of staged protocols have been developed. However, there is a lack of evidence establishing which surgical procedure is the most effective. The soft palpate can be addressed by uvulopalatopharyngoplasty (UPPP), while the retrolingual, oropharyngeal, and hypopharyngeal areas can be improved with procedures such as genioplasty and hyoid suspension. Maxillo-mandibular advancement has also been shown to improve posterior airway space. There is a lack of data to support an indication for the EASE procedure for the treatment of this patients mild OSA. All told, the requested EASE procedure is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is licensed D.D.S., board certified in orofacial and maxillary surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic low back pain and fibromyalgia.Findings: There is a lack of peer reviewed evidence based studies which support Norco as an effective treatment in this clinical setting. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, there were no objective treatment goals for pain and function noted. Several requirements for opioid prescribing were not documented. Thus, the request for Norco as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) recommends that when opioids are started, clinicians should prescribe the lowest effective dosage. Additionally, the records do not mention if behavior therapy has been performed, despite much research to support its use. As such, the medical necessity of Norco for treatment of this patients medical condition has not been established in this case.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.