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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Upheld

A 27-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the records indicate that the patient was eating and sleeping well, and participating in groups during her admission. As of the date in question, the patient was voluntarily taking her medication. In addition, there is no documentation of any issues which required the intensity of treatment provided at the acute psychiatric level of care. Further, the medical literature favors outpatient treatment when feasible. All told, the services provided during the said time frame was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vascepa.Findings: Approved indications for the use of Vascepa based on randomized published data from a trial, and U.S. Food and Drug Administration (FDA) indications include severely elevated triglycerides greater than 500 mg/dL or triglycerides greater than 150 mg/dL in patients on maximally tolerated statin therapy with either established symptomatic coronary artery disease or diabetes and two other risk factors for coronary artery disease. In this case, the patient has mild elevation of triglycerides, but is not on statin therapy. There is no clinical documentation of established coronary artery disease or diabetes. Based on published randomized trial data and FDA approved indications, the patient does not meet the current published criteria for Vascepa therapy. Thus, Vascepa is not medically necessary for the treatment of the 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 internal medicine with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a vertical laparoscopic sleeve gastrectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  The records do not document a BMI of 35 or greater with serious weight-related comorbid conditions such as diabetes, hypertension or sleep apnea.  Sleep apnea is not documented, as the patient had a normal AHI.  The records do not document a dietary evaluation.  There is a lack of support for the requested services in this patients case.  All told, the requested vertical laparoscopic sleeve gastrectomy is not medically indicated for the 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 board certified in 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 for a sleep study for evaluation of the enrollees snoring. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There is no Epworth Sleepiness Score documenting daytime hypersomnia, which is a cornerstone for a diagnosis of sleep apnea.  Per the medical records, the patient is not obese. There is no documentation of an elevated Mallampati score.  His consistent outstanding symptom is loud snoring, and this is not an indication for a sleep study.  The patients history is inconsistent and has changed since the initial requested sleep study was denied.  The patient indicated that he has difficulty falling asleep.  This is generally not a symptom of clinically significant sleep apnea, since patients with clinically significant daytime hypersomnia usually have decreased sleep latency.  Snoring and sleep onset insomnia are not indications for a sleep study.  All told, the requested sleep study is not medically indicated for the evaluation of this patient.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 internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori antibody testing (CPT code 86677).Findings:  Three physician reviewers found there is a lack of support for the services at issue in this clinical setting. If there is concern that the patient may still have Helicobacter pylori infection or had reinfection, then there are three recommended ways to test. These methods of testing include biopsies via endoscopy, checking for stool antigen, or performing a urea breath test. An antibody level will be positive in patients who have been previously treated and cannot discern active infection. Therefore, Helicobacter pylori antibody testing (CPT code 86677) was not likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

The patient is 33-year-old female who is status post duodenal switch bariatric surgery.  Abdominoplasty and panniculectomy were performed approximately one year ago.  The record indicates she has a reported body mass index (BMI) of 39. The patient is now seeking further body contouring procedures, specifically, a belt lipectomy for redundant buttock folds and excess thigh tissue. The patient has been evaluated by two plastic surgeons, and has sought other consultations for support of her request for her excess skin removal. The Health Plan has denied authorization and coverage for the requested surgery stating it is considered cosmetic and therefore not medically necessary. The submitted records include statements from the patient, photographs, and consultation reports. These materials do not establish medical necessity for a belt lipectomy or a buttock/thigh lift. There is insufficient objective evidence of a functional impairment resulting from the patients excess skin and tissue. These procedures are cosmetic in nature and are not medically warranted. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested  for speech therapy and occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 state, The immediate and long-term evaluation and monitoring of autistic patients requires a comprehensive multidisciplinary approach, and can include psychologists, neurologists, speech-language pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The recommendations include a thorough evaluation of sensorimotor skills by a qualified experienced professional for assessment of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the patients life. Studies have shown that occupational therapy prevents deterioration or reversal of function and can result in significant improvement in ADLs. In 2008, Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and showed that in all six areas occupational therapy significantly helped the patient. Another example of a patients account of how occupational therapy improved his ADLs over a 5-year period was documented by Shoener. Occupational therapy is considered medically necessary if, in a predictable period of time, the therapy is likely to achieve a significant measurable improvement in mobility or ADL functions. Based on the information provided, this patient meets these criteria.As part of a comprehensive treatment regimen, occupational therapy combined with speech therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for young patients who have ASD. It is well accepted that speech therapy is medically appropriate and required to treat children with autism. Given this patients significant receptive, expressive and social language delays, his deficits encompass greater communication difficulties than those categorized as educational in nature.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin therapy.Findings:  Two out of three physician reviewers found that in this patients case, the records document anti-sulfatide polyneuropathy. Enrollee has severe pain, functional limitations, gastrointestinal symptoms and spasticity. Given the overall clinical picture and the possibility of an underlying autoimmune etiology, provider has recommended intravenous immune globulin therapy. There is medical evidence which supports immunomodulation in the form of intravenous immune globulin therapy for patients with an autoimmune neuropathy. Without intervention, this condition can progress and may result in significant disability. Therefore, intravenous immune globulin therapy is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld

The parent of a 16-year-old male enrollee has requested Menaflex meniscal implant for treatment of the enrollees knee pain. Findings:  Two physician reviewers found that the long-term result of use of the requested device remains unknown at this time. There is a lack of well-controlled, randomized, prospective clinical trials in the peer-reviewed literature supporting the use of collagen meniscal implants in the setting of adult patients who are status post meniscectomy.  There are no such studies involving skeletally immature patients. In this patients case, there is a lack of evidence supporting the superior efficacy of a collagen meniscus implant over alternative treatment options. As noted by Tice, the long-term safety and efficacy of the device has not yet been established.  In this patients case, Menaflex meniscal implant is not likely to be superior over alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a psychoeducational assessment test. Wolraich and colleagues note, The use of neuropsychological testing has not been found to improve diagnostic accuracy in most cases, although it may have benefit in clarifying the child or adolescents learning strengths and weaknesses. The American Psychological Association notes that psychological and neuropsychological testing is not medically indicated when administered for educational or vocational purposes that do not inform medical or health management such that the purpose of testing is not to alter or direct medical or health management, or when repeat testing is not required for medical decision-making; for example, because the repeat testing is because of a patient preference or request. In this case, the patient underwent previous psychological testing and was diagnosed with attention deficit hyperactivity disorder (ADHD). The request for updated testing is from an academic support specialist at the patients school and not from a clinician. The documentation does not show that the testing is for a reevaluation of the patients diagnosis or clinical treatment plan. In this patients case, a psychoeducational assessment test is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, a psychoeducational assessment test is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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 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

The parent of a three-year-old male enrollee requested speech therapy three times per week for medical treatment of the enrollees speech delay. Findings:  The physician reviewer found that based on the available medical records, this patient is profoundly speech delayed, but there is evidence that his speech delay is at least partly due to intellectual developmental factors. Whether increased frequency of speech therapy will accelerate the development of speech in a cognitively delayed child is not well defined in the medical literature (Goorhuis-Brouwer and Kniff).  In regard to cognitively impaired children, there is a paucity of data addressing with the impact of frequency and intensity of speech therapy in a child who is intellectually delayed. Given these findings, the requested three hours per week of speech therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Keytruda. The U.S. Food and Drug Administration (FDA) has not approved Keytruda for the treatment of patients with pancreatic cancer. In addition, there is a paucity of medical literature demonstrating improved patient health outcomes with Keytruda. Currently, the treatment of patients with Keytruda is limited to the treatment of unresectable or metastatic microsatellite (MSI) high or deficient mismatch repair (dMMR) solid tumors that have progressed following prior treatment and have no satisfactory alternate treatment options. Moreover, the National Comprehensive Cancer Network (NCCN) does not include Keytruda as a recommended agent in the management of patients with pancreatic cancer. Overall, there is a lack of data to support use of Keytruda in addition to folinic acid, fluorouracil, irinotecan hydrochloride, and oxaliplatin (FOLFIRINOX) for neoadjuvant treatment of pancreatic cancer. For these reasons, the requested Keytruda is not medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 59-year-old female enrollee has requested continued speech therapy for treatment of her fruste ataxia.  Findings:  The physician reviewer found that in this patients case, the submitted documentation does not establish the medical necessity of continued speech therapy.  Physician notes were not submitted for review.  Thus, although therapy notes indicate a diagnosis of fruste ataxia, the actual diagnosis was not documented.  The medical literature endorses speech therapy for specific diagnoses including recovery post stroke or post brain injury.  All told, the requested speech therapy is not medically indicated for this patient.  There is insufficient support for continued speech therapy at this time based upon the provided records.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy. Swanson note that evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. For a patient with acute symptoms of bipolar disorder, psychotherapy once weekly with additional group psychotherapy and case management, as needed, is appropriate. In this case, the patient has a diagnosis of bipolar disorder and is destabilizing rapidly at this time, to the point of needing crisis services.  In this clinical setting, the requested services are standard of care and medically indicated. Therefore, weekly psychotherapy is medically necessary for the treatment of 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 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 requested comprehensive orthodontic treatment of the adolescent dentition, oral/facial photographic images, and cephalometric radiographic image for treatment of her overbite, overjet, and anterior crowding.  Findings:  The physician reviewer found that the records document that this patient does have a malocclusion with increased overjet and an overbite. Orthodontic treatment is indicated for the guidance of the dentition and supporting structures to attain and maintain optimum relations in physiologic and esthetic harmony among facial structures. The current medical literature supports the requested services in this clinical setting. All told, the requested orthodontic treatment of the adolescent dentition, oral/facial photographic images, and cephalometric radiographic image is supported as dentally necessary for treatment of this patients medical condition.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 oral and maxillofacial 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.