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

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Moreover, treatment-naive patients are recommended to be treated with Harvoni for 12 weeks (Class I, Level A recommendation). Therefore, the request for Harvoni is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review indicate that she was still triggered by the past sexual assault. She also identified family stress as her other main trigger. However, the progress notes indicate that she had a good family session and enjoyed seeing her parents. Subsequent notes indicate that she had gained insight into her triggers and had developed and practiced coping skills successfully. Therefore, the patient could have continued treatment at a lower level of care. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition.  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: Upheld

A 24-year-old male enrollee has requested acute inpatient psychiatric services for the treatment of his bipolar disorder. Findings:  The physician reviewer found that an overall analysis indicates there were no psychotic symptoms as the patient was a low risk of harm to himself and others. The patient had moderate functional impairment and his judgment on admission was noted to be good. His mood was described as slightly elevated.  There were minor co-morbidity issues but no medical problems that required an acute level of care. The patient was compliant with medication but required a higher dose. He could have been appropriately treated at a less intensive level of care. Based on the Level of Care Utilization System (LOCUS) and the American Psychiatric Association (APA) practice guidelines, medical necessity for acute psychiatric hospitalization has not been established in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued speech therapy. The requested continued speech therapy is medically necessary for treatment of the patients medical condition and should be used to transition the patient to applied behavioral analysis (ABA) therapy. The available records do not support that the patient is making measurable progress with speech therapy and utilization of speech therapy sessions by the patient has been suboptimal. Speech therapy for six months will permit transition to ABA therapy and ameliorate deterioration in behavior and regression of previously acquired speech skills. Behavioral and developmental regression during the COVID-19 pandemic has been described by many parents of children with autism spectrum disorder. Researchers concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal patients with developmental disabilities. Researchers found that treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech and language, occupational, and physical therapies. Given these findings, continued speech therapy is medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions.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 board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for MitraClip transcatheter mitral valve repair (CPT 33418). Armstrong and Foster note that transcatheter mitral valve repair (TMVR) is a minimally invasive technique for treatment of selected patients with symptomatic chronic moderate-severe or severe (3+ or 4+) mitral regurgitation. Other indications for MitraClip include severely symptomatic heart failure despite medical therapy, favorable anatomy for the repair procedure, reasonable life expectancy, and prohibitive surgical risk due to comorbidities. OGara and colleagues note that perioperative mortality rates for selected, low-surgical-risk patients with severe degenerative mitral regurgitation is now less than 1% in major referral centers where a successful repair can be accomplished in over 95% of patients with isolated posterior mitral leaflet pathology. Reduction in mitral regurgitation by TMVR using the MitraClip is associated with improvement in both functional and quality-of-life metrics. Therefore, the requested MitraClip transcatheter mitral valve repair (CPT 33418) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MitraClip transcatheter mitral valve repair (CPT 33418) is 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal cord stimulator (CPT 62350) for treatment of her transverse myelitis. Findings:  Two physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with chronic back pain and lower extremity symptoms. She had an acute neurologic event years ago with residual symptoms. There is no documentation the patient has tried physical therapy, transcutaneous electrical nerve stimulation (TENS), injections, behavioral therapy, or a back brace in the last 24 months. In addition, there is no documentation of an electromyogram (EMG) to rule out peripheral neuropathy for her burning pain. For the reasons provided, the spinal cord stimulator trial is not medically appropriate for this patient. Final Result: The reviewers determined that the requested procedure 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: Reviewers 1, 2, and 3 are board certified in neurological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested authorization and coverage for chemical dependency residential treatment services for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that clinical guidelines and patient placement criteria for patients with substance dependence have been developed to assist with the determination of the appropriate level of care, and it is the task of physicians and therapists working directly with the patient population to interpret and apply these tools. In this particular case, the patient required multiple acute admissions and most recently has failed intensive outpatient programming. It is clear that the pattern of substance use in this case jeopardizes the patients physical and mental well-being in addition to posing a risk to others as well.  Further, a thorough assessment, which applied American Society of Addiction Medicine criteria, has recommended a residential treatment level of care for the patient. A placement in the residential setting affords the time and comprehensiveness for the consolidation of treatment gains necessary to allow the patient to succeed in the community setting. Considering the patients clinical presentation, history and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested services in this case are safe, appropriate, and consistent with good clinical practice in the psychiatric community. In sum, chemical dependency residential treatment services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested fentanyl patches for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support the requested medication in this clinical setting.  This patient failed to attend pain management visits.  Additionally, all non-opioid treatment options for her chronic pain have not been utilized.  The records do not document optimization of all non-opioid medications.  There is no plan in place to monitor this patient with the requested medications from her primary doctor.  Multiple minimal requirements for opioid prescribing have not been done and the need to use this medication as the primary treatment strategy for pain has not been established.  All told, the requested fentanyl patches are 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: Overturned

The enrollees parent has requested authorization and coverage for services in a social skills group for autism spectrum disorder. The enrollee began receiving relationship development intervention services, engagement in a social skills group, occupational therapy, and speech therapy services.  During the initial psychiatric evaluation, the enrollee demonstrated significant developmental concerns; including stereotyped and repetitive use of language, idiosyncratic language, inflexible adherence to specific, non-functional routines or rituals, overreaction when given direction, and hypersensitivity to noise, textures, smells, and taste. He demonstrates delayed social communication skills, which impact his ability to explain how he feels, describe recent experiences, and engage in meaningful conversations without the communication breakdowns caused by difficulties with clarification and expansion of ideas. The enrollee previously received therapy services and received 1.5 hours per week of behavior-based social skills services and 54 hours of parent consultation over a six-month period. He met his speech goals at this provider and was within the average range when compared to his peers. Due to the enrollees age, he may no longer benefit from intensive traditional applied behavioral analysis, evidencing a plateau in the presentation of his progress. Therefore, it appears appropriate to modify the enrollees treatment regimen to community-based treatment services to assist him in maintaining his skills and generalizing them to the community. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is a Licensed Marriage Family  Therapist (LMFT), is a Doctor of Psychology, 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: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollees left-sided thoracic mass lesion. Findings:  The physician reviewer found that The Guardant360 gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presented with suspected soft tissue sarcoma but no evidence of biopsy proven cancer. Molecular profiling with Guardant360 testing is used on patients with biopsy proven malignancies to help guide therapy decision making and is not indicated for every malignancy. Performing Guardant360 without biopsy proven disease is premature. Based on the clinical documentation submitted for review, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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

A 60-year-old female enrollee has requested for percutaneous repair of the mitral valve with the MitraClip for treatment of his heart condition.   Findings:  Two physician reviewers found that mitral valve repair is indicated when severe mitral regurgitation is accompanied by evidence of left ventricular dysfunction, even in an asymptomatic patient. There is significant morbidity and mortality associated with valve replacement or repair when performed in patients with low ejection fractions (see Bishay and colleagues). The development of a percutaneous approach in selected patients with functional and non-functional forms of mitral regurgitation has provided another treatment option for these high-risk patients. The Everest II (phase III) clinical trial results demonstrate the non-inferiority of the MitraClip device for repairing regurgitant mitral valve lesions compared to standard open heart surgical repair or replacement. Furthermore, the results demonstrated that there was no difference in the need for subsequent mitral valve surgery through two years between patients who underwent open heart surgery versus the patients who used the MitraClip device. Therefore, these results, combined with the fairly high risks of open heart surgery and its attendant potential morbidity and mortality, support the position that percutaneous MitraClip mitral valve repair is likely to more beneficial for this patient than mitral valve repair via open heart surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. 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. As noted by ASAM guidelines the duration of treatment always depends on an individuals progress in acquiring basic living skills and how long a person stays in a 24-hour treatment setting depends on his ability to apply and demonstrate coping and recovery skills. This patient has not yet attained the skills needed to maintain recovery. The patient is at high risk of acute or subacute withdrawal as evidenced by visible hand tremor, agitation, and severe cravings rated as 8/10. Continued use places the patient health at serious risk as evidenced by his liver status. He is taking Clonidine 0.1 mg and he required a benzodiazepine taper at the beginning of his admission. The patients mental status is sufficient to permit participation in treatment and he has been unable to control his substance use without 24-hour support. He requires a 24-hour milieu treatment to support his recovery and formulate a relapse prevention plan. The patient described that his feelings of resentment fuel his desire to drink alcohol. The patient is experiencing intense cravings, which place him at high risk for relapse due to his psychosocial stressors and poor coping without treatment in a supportive 24-hour setting. The patients recovery environment is a major trigger for his substance abuse and would not facilitate his goal to achieve and maintain sobriety. All told, the RTC services were and are medically necessary for treatment of this patient. 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 psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that in this case, the patient would likely be non-compliant in an IOP/PHP program, as already determined by the staff at the program to which she applied. She has chronic, serious symptoms that require an intensive, coordinated treatment approach. Thus, RTC level of care is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested for growth hormone (GH) therapy with Humatrope for treatment of her presumed hormone deficiency.         Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists guidelines indicate that adults selected for GH therapy should have an easily recognized cause, clear cut clinical features of the adult syndrome and non refutable laboratory evidence of growth hormone deficiency. The guidelines also indicate that stimulation tests using arginine and growth-hormone-releasing hormone (GHRH) have been accepted as more stringent than tests using arginine or levodopa alone. Other studies that indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old woman with chronic back pain radiating to her right lower extremity. She states she has numbness. She has attempted use of medication, physical therapy, chiropractic, and exercises. An MRI was performed in 2003. The study was repeated in June 2005 at the request of the patients treating neurologist. At issue is whether the repeat MRI was medically necessary for evaluation of the patients medical condition.Review of the submitted clinical evidence indicates the MRI at issue was medically reasonable and appropriate. The patient has had chronic pain with failure of conservative treatment and radicular complaints. The study was performed to evaluate her for facet hypertrophy, neural impingement, stenosis, disc herniation, etc. and to see if surgery was an option. The MRI was reasonable, clinically indicated and the appropriate test at the time. Therefore, I have determined the MRI at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.