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

Nature of Statutory Criteria/ Case Summary:  The patient has requested authorization and coverage for Intravenous Immunoglobulin (IVIG) Administration at an Outpatient Hospital Infusion Center. She has Stage 3 Chronic Lymphocytic Leukemia (CLL) and is enrolled in a clinical trial for the CLL using ibrutinib and venetoclax. Oncology notes indicate she is immunosuppressed.  She has also been getting IVIG infusions and has had infusion reactions with skin infections. After the first IVIG transfusion, she developed pneumonia and then olecranon bursitis with Pseudomonas infection.  She had been receiving the IVIG at an infusion center. However, the health plan denied coverage indicating that she needed to have home infusion services. Her physician indicates the patient has had several issues that were handled in the infusion center and home health infusion is not recommended for this patient. As per the medical literature, some adverse events can occur during the infusion or a few days afterwards; these represent approximately 40 percent of all adverse reactions to IVIG and include thromboembolic events or complications affecting the central nervous system, kidney, or blood cells. A home infusion and home injectable therapy would not be appropriate given the patients prior reactions to the IVIG. This patient has unique circumstances including Chronic Lymphocytic Leukemia. The patient had a prior reaction, which would increase the likelihood that she would have future reactions. Any reaction may produce dire consequences due to her complex medical history and current clinical situation. The patient needs close monitoring and observation. Thus, the outpatient hospital infusion center is appropriate. Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the patients condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in Hematology and Oncology and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested robotic-assisted prostatectomy (da Vinci prostatectomy) for the treatment of his prostate cancer. Findings:  Two physician reviewers found that robotic-assisted prostatectomy is this patients best option for the treatment of his cancer. The potential benefits include decreased blood loss, minimal pain, shorter hospital stay and better preservation of continence and potency. Furthermore, the scientific literature suggests there is better cancer control with the robotic-assisted approach compared to traditional open surgery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollees apraxia. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, involves impairment in planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. It is a neurological disorder that requires intensive treatment. If left untreated or inadequately treated, communication at all levels may ultimately be impaired. This patient has verbal apraxia and dysarthria, and his skills fall below those of other children his age. These deficits negatively impact his ability to communicate effectively. Studies have shown that speech therapy can result in significant improvement in such patients. This patient has demonstrated some improvement with previous speech therapy and is likely to benefit from additional therapy. Thus, speech therapy was and is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Gel-One injection in the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a history of severe pain in the right knee that did not respond to cortisone injections, medications, rest, heat, and restriction of activities. Records reflect that the patient was recuperating from shoulder surgery and was unable to undergo a total knee arthroplasty. Under these circumstances, the provider recommended viscosupplementation to relieve pain and delay total knee arthroplasty. Therefore, the Gel-One injection in the right knee was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor male enrollee has requested reimbursement for adolescent residential mental health treatment services. According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter on OCD, cognitive behavioral therapy (CBT) is considered the first-line of treatment for mild-to-moderate cases of OCD. For patients with moderate-to-severe cases of OCD, the AACAP recommends a combination of CBT and medication management. The AACAP noted that treatment resistance is considered when a patient has persistent OCD symptoms despite engaging in adequate treatment that has been demonstrated to be effective. A research study on residential treatment for adolescents with OCD noted that patients with complex comorbidity or previous unsuccessful treatment attempts may require more intensive monitoring, multimodal interventions, and greater intensity of treatment delivery than even intensive outpatient CBT provides. The authors further reported that residential treatment provides a greatly increased number of hours of CBT provided per week (Leonard, et al). The patient in this case has a history of failing treatment with medications as well as outpatient and IOP levels of care. The records indicate that discharge prior to 8/10/18 would have been premature and likely resulted in relapse. Overall, the current medical literature and practice parameters support that the treatment at the residential level of care was appropriate for continued management of this patients behavioral health issues. Thus, the adolescent residential mental health treatment services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old male who was diagnosed with metastatic renal cell cancer in January 2005. He was initially diagnosed following VATS and lung biopsy for a left pleural effusion, at which time he also underwent talc pleurodesis. His primary was identified as the right kidney and he underwent a right nephrectomy in March 2005. He was treated with systemic therapy for his metastatic disease with IL-2 and interferon, which was changed to Avastin and interferon in August 2005. The patient had a PET scan in September 2005 demonstrating uptake of the left lung, ribs, posterior neck and soft tissue adjacent to the maxilla. Treatment was then switched to sorafinib with the persistence of metastatic, though stable, disease. By report, his last PET scan revealed only a single mass in the left lung that demonstrated FDG uptake. His latest CT scan demonstrates mild enlargement of the left pulmonary lesion (3.1 x 3.2 cm in January 2006, which increased to 3.1 x 4.1 cm as of April 2006).The patient was discussed at a multidisciplinary tumor board at which time it was recommended that his enlarging left lung mass be treated. All other metastatic disease was felt to be stable, and it was felt worthwhile to treat this enlarging tumor. Options discussed were surgery and radiation therapy. The thoracic surgeon felt that the risks of surgery were too great due to the previous talc pleurodesis, and therefore radiation was preferred. The radiation oncologist recommended Cyberknife therapy. At issue is whether Cyperknife therapy is medically necessary for treatment of the patients medical condition.This patient who has metastatic renal cancer has been treated with a variety of systemic therapies (IL-2/IFN, IFN/Avastin and sorafinib). He has an enlarging metastasis of the left lung. A request has been made for Cyberknife therapy. Alternative therapies consist of surgical treatment, additional systemic therapy or other forms of radiation therapy.Given the metastatic nature of the patients disease, the goal of therapy is local disease control and palliation of this pulmonary lesion. However, the patient is currently asymptomatic and there is no role in treating the lesion with the goal of improving survival. Given the risks of re-operative thoracic surgery in this patient with prior pleurodesis, other non-operative measurements are more appropriate. Though radiation therapy is a reasonable modality, data on the use of Cyberknife in metastatic disease is limited. The two submitted reports show reasonable disease control rates, but there is no data related to renal cell cancer or any data comparing this modality to traditional external beam. Given the availability of other potential treatment modalities (e.g., traditional radiation therapy), the limited data on Cyberknife therapy, and the goal of symptomatic disease control in this asymptomatic patient, the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 5-325 mg for treatment of the enrollees acute stroke with right-sided lumbar pain with radiation to right leg. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. This patients records do not include documentation of objective treatment goals for pain and function supporting an indication for Percocet. In addition, the records do not document completion of behavior therapy despite much research to support its use. Moreover, not all non-opioid medication classes have been optimized. Also, the need to use opioids as the primary medication treatment strategy for this patients pain has not been established. All told, the requested Percocet 5-325 mg is not medically necessary for treatment of this patients medical condition. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) guided focal laser ablation of prostate cancer for treatment of his medical condition.  Findings:  Three physician reviewers found that the use of focal therapy of prostate cancer is not considered standard of care by the majority of urologists.  The medical guidelines do not comment on utilization of focal therapy for treatment of prostate cancer.  Many forms of energy are utilized to provide focal therapy. Only a few studies have evaluated the efficacy of MRI guided laser therapy for the treatment of prostate cancer.  These are phase 1 studies involving a small number of patients. The criteria for successful treatment are largely unknown, and there is a lack of long-term follow-up available.  All told, MRI guided focal laser ablation of prostate cancer was not likely to have been superior over other treatment options.  Final Result:  Three 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:  All three reviewers are board certified in urology 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 50-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for the evaluation of her for breast cancer.  Findings:  The physician reviewer found that this patient does not meet the current accepted criteria for screening for breast cancer using MRI. The current accepted practice is to perform a mammography and ultrasound of the breasts as screening and follow-up procedures as a first-line of defense in the detection of breast cancer. This patient has a history of lumpectomy; there is no indication in the submitted records that the original lesion was associated with positive margins or lymph node metastases. The patients given family history is positive, but there is no personal history of positive BRCA-1 genetic testing or positivity for the marker. Currently, the practice guidelines recommend that MRI be reserved for use as a problem solving tool given either equivocal mammographic or sonographic findings, or physical findings not explained by conventional imaging. This patient has had unremarkable and stable mammograms for several years. Thus, the patient does not meet current accepted criteria for MRI screening of the breasts and the requested diagnostic procedure is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) eating disorder services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the residential treatment eating disorder services were medically necessary for treatment of the patients medical condition. There is no single diagnosis in and of itself that meets typical criteria for residential placement in this case. However, the confluence of her medical conditions and distorted schemas, and their concerning totality of sequelae and subsequent functional impairment, warranted aggressive treatment in a supervised setting. Further, the quick re-admission to the residential level of care represented a significant variable in support of a conservative hospitalization. In the days leading up to discharge, the patient was described as anxious, disconnected and disengaged. She required medication for her anxiety. She felt that she was overweight. She was angry that she was gaining weight. She engaged in eating disordered behaviors at meal time. Her blood sugars were inconsistent, ranging from 61 to 324. She needed nursing assistance with insulin administration and her insulin pump was not working properly. Moreover, her treating providers recommended continued residential treatment. Longitudinally, the patient had struggled with eating disordered-behaviors in context of diabetes since adolescence, and she had previously failed treatment in less restrictive settings. Based on the entirety of data, safe and effective treatment could not have been reasonably provided in a less restrictive setting. The residential placement was reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition.Final Result: The reviewer determined that the services at issue were 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 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 residential treatment center services for treatment of his behavioral health condition. Findings: The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, residential treatment center services were not medically necessary for this patient. The submitted documentation demonstrates that the patient was not experiencing post-acute withdrawal symptoms and he was not a danger to self or others. The medical records show he was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive indicators to warrant residential level of care.  He endorsed motivation for recovery.  The progress notes indicate that he was cooperative and compliant with care.  He lived with someone who was sober and supportive. There was no evidence that the patient would not respond to treatment at a lower level of care.  He did not require 24-hour supervision in a residential setting and could have been treated in an intensive outpatient program (IOP). Studies support that IOP level of care can be as effective as inpatient level of care in the treatment of alcohol and drug addiction. As such, residential levels of care services were not medically necessary for management and treatment of the patients behavioral health 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.Qualifications/Credentials: The physician 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

The parent of a 14-year-old male enrollee has requested for inpatient residential care for treatment of the enrollees condition. Findings:  The physician reviewer found that tt is clear that the patient does not need 24-hour supervision at the inpatient residential level of care.  The patient was not noted to be a danger to himself or others, unable to care for himself or psychotic.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested amphetamine salt 30mg, three times per day for treatment of her diagnosis of attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage.  This patient has requested coverage for a psychostimulant at a dose in excess of clinical recommendations and standard practice.  The medical records do not show that the patient has failed long-acting stimulant options which provide up to 12 hours of coverage with a single dose.  There is a lack of well-developed studies in the peer-reviewed literature that demonstrates both superiority and safety of amphetamine salts at dosages greater than 60mg daily.  The current medical literature does not support the requested medication dosage in this clinical setting.  All told, amphetamine salt 30mg, three times per day is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Otezla is a U.S. Food and Drug Administration approved treatment for psoriasis and psoriatic arthritis. In this case, the patient has chronic plaque psoriasis and has failed therapy with topical steroids and Enbrel. However, the Health Plans recommendation for treatment failure of two formulary alternatives that include Humira and Cosentyx is medically reasonable and appropriate. Given the lack of treatment failure, contraindication or intolerance to at least two of the preferred medications, the request for Otezla has not been established as medically necessary for treatment of the patients chronic plaque psoriasis. 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.