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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for chemical dependency group classes. for the treatment of cannabis use, referred by a court mandate.  The intake assessment indicates a maximum of two months of abstinence in the past 12 months and a maximum of one year of abstinence since initiating substance use.  His speech and behavior were disorganized. However, he was able to track conversations, but was restless and nervous. He had a restricted affect and expressed paranoid ideations. Per the enrollee, he was diagnosed with schizophrenia, undifferentiated. Assessment showed the enrollee met DSM-V criteria for cannabis use disorder, moderate.  The provider recommended the day treatment level of care, cognitive approach to chemical dependency.  Some of the behaviors noted during the chemical dependency group class included disengagement from the group, not completing workbook assignments and laughing during class inappropriately.  His marriage and family therapist recommended a reassessment by psychiatrists and mental health care providers before returning to the chemical dependency group class. Per assessment/intake documentation, the enrollee denied use of any substances, except nicotine and cannabis.  He reported smoking one-half pack per day of cigarettes and marijuana weekly since age 12, but denied any use in the previous 30 days.  In the absence of reported substance use, his presentation suggests the possibility of psychotic symptoms. Olanzapine was reportedly prescribed; however, there is insufficient evidence in the record of his last psychiatry visit or compliance with his medications.  In addition, cigarette smoking decreases Olanzapine levels.  In regard to the enrollees presentation during chemical dependency group classes, schizophrenia can impact multiple areas of cognition; such as processing speed, attention, working memory, visual learning and memory, verbal comprehension and social cognition. Based on the information in the record, this enrollee is not able to participate in chemical dependency classes in his current condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.  Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for neuroplasty/decompression of the greater and third occipital nerves for treatment of the enrollees headaches.   Findings:  Two physician reviewers found that the patient has a history of chronic headaches.  These headaches have failed to respond to various modalities of treatments.  The medical records noted that two series of forehead Botox injections only provided approximately 50% improvement for a few weeks, after which time her headaches returned to their baseline level. The patients symptoms include nausea, vomiting, diarrhea, photophobia and lightheadedness.  The patient has requested coverage for neuroplasty/decompression of the greater and third occipital nerves.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. The current medical literature has not demonstrated the superior efficacy of the requested services. The neurovascular compression of the greater occipital nerve and its implications for migraine headaches has been described. The study by Janis and colleagues showed that the greater occipital nerve and occipital artery have an anatomical intersection 54% of the time. Thus, migraine headaches may originate from the occipital region.  In a review of indications and outcomes for surgical treatment of patients with chronic migraine headaches caused by occipital neuralgia, Ducic and colleagues described 206 consecutive patients undergoing neurolysis of greater or, less commonly, excision of greater and/or lesser occipital nerves. In this retrospective evaluation, the authors found that over 80% of patients experienced at least 50% pain relief.  However, at this time, there is a lack of controlled studies or observational studies utilizing a large number of patients. All told, the requested neuroplasty/decompression of the greater and third occipital nerves is not likely to be more efficacious than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Two physician reviewers found that tomosynthesis is approved for clinical use by the U.S. Food and Drug Administration (FDA), and the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Overturned

The patient has requested authorization and coverage for Yescarta therapy (CAR-T immunotherapy). Prior studies of autologous or allogeneic stem cell transplantation for relapsed DLBCL DHL demonstrate poor health outcomes and no significant clinical benefit following induction chemotherapy (Herrera, et al.; Landsburg, et al.). In a study of outcomes for patients with DHL who achieved a first complete remission following induction chemotherapy, consolidative autologous stem cell transplant was not associated with improved three-year relapse-free survival or overall survival (Landsburg, et al.). Studies on Yescarta CAR-T (chimeric antigen receptor T-cell) therapy have demonstrated induction of durable responses and manageable long-term safety. One recent study reported significant benefit for relapsed or refractory DLBCL, including DHL with Yescarta CAR-T therapy at two-year follow-up (Locke, et al.). All told, Yescarta therapy (CAR-T immunotherapy) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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 43-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her diffuse large B-cell lymphoma.  Findings:  Three physician reviewers found that PET/CT scanning with F-18 FDG, an isotope of glucose, is an extremely helpful scan which can reveal areas of increased metabolism often associated with a wide variety of cancers, including high grade lymphomas. PET/CT has become a standard means of initial staging and for evaluating the effectiveness of treatment in many cancer types including lymphomas (Isohashi, et al; Juweid, et al). In this patients case, her initial staging PET/CT scan showed intense uptake in the areas of her lymphoma. Therefore, the requested follow-up PET/CT scan is likely to be more helpful to make clinical decisions for this patients care than any other testing or diagnostic procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested computed tomography (CT) angiogram of the heart and coronary arteries for treatment of her ventricular septal defect status post repair.  Findings:  Three physician reviewers found that CT angiogram is an accurate technology capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner. No other non-invasive technology is capable of performing this feat with the clarity, speed, and accuracy than CT angiogram. However, based on the most recent guidelines, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not recommend the use of CT angiogram of the heart in asymptomatic patients. Thus, this patient does not currently meet the criteria for the requested CT angiogram of the heart and coronary arteries. All told, the requested services are not likely to provide greater benefit in evaluating and treating this patients medical condition than standard risk stratification and testing.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee has requested Intacs procedure for treatment of her keratoconus.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Keratoconus is a degenerative disease of the cornea of the eye that causes the cornea to thin and change its curvature.  In extreme cases, the cornea becomes conical in shape.  Patients with keratoconus have symptoms such as blurred vision, sensitivity to light, eye strain, and the perception of multiple ghost images.  The visual symptoms experienced by keratoconus patients are often due to various forms of optical aberration induced by the irregular shape of the cornea.  Treatment of keratoconus generally begins with glasses or contact lenses.  Surgical treatment of keratoconus includes the insertion of intrastromal corneal ring segments, also known as Intacs, corneal transplantation, and deep anterior lamellar keratoplasty, a procedure in which only the outer layers of the cornea are replaced.  The published literature suggests that Intacs may prevent progression of keratoconus, may be useful in treatment of subclinical keratoconus, and may even be an option in patients with advanced keratoconus.  This patient no longer has adequate functional vision based on her visual symptoms despite the use of glasses and contact lenses, her corneas are clear, and the corneal thickness is adequate.  Because of its inherent risk and unpredictability, corneal transplantation is not a viable option in keratoconus patients such as this patient with good correctable vision but significant visual symptoms due to optical aberration.  Deep anterior lamellar keratoplasty has a similar risk profile to corneal transplantation.  All told, the requested Intacs procedure is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or others.  The patient required monitoring but did not require partial hospitalization program level of care to do so.  She was not aggressive towards others and was not psychotic or manic.  She was medically stable.  She was cooperative and compliant with her medications and suffered no side effects.  The patient continued to suffer from depression, anxiety, and obsessive thoughts around her eating disorder but this could have been managed at a lower level of care.  Her parents participated and received education.  Although motivated, the patient still struggled with compliance regarding exercise and required some supervision with her meal plan.  However, given the progress she had made, she no longer required the structure of monitoring at two meals and in between meals which would be provided in partial hospitalization program level of care.  Per the medical records, the patient could have continued treatment for her eating disorder at a lower level of care.  All told, the partial hospitalization program level of care services at issue was not medically indicated for the treatment of this patient.   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 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 62-year-old female enrollee has requested hydrocodone-acetaminophen 7.5/750mg (Vicodin ES 7.5/750mg), quantity 100 and morphine ER 30mg, quantity 180 for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this patients case.  Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy and injections to help reduce pain.  Opiates are considered adjunctive to this treatment.  The current medical evidence does not support the requested medications in this clinical setting.  Baron and McDonald reported that the use of high-dose opiates may contribute to pain sensitization.  High-dose opiates are more likely to cause adverse outcomes.  Ballantyne and Mao noted that use of high-dose opiates may result in abnormal pain sensitivity and tolerance.  All told, hydrocodone-acetaminophen 7.5/750mg (Vicodin ES 7.5/750mg), quantity 100 and morphine ER 30mg, quantity 180 are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The appointed representative for a seven-year-old female enrollee has requested for orthoptic training (vision therapy) for treatment of the enrollees accommodative esotropia. Findings:  The physician reviewer found that no visual symptoms or complaints were documented. One vision therapy visit mentions a history of occlusion treatment, although the visual acuity decrease was bilateral. A unilateral amblyopia does not appear to exist with this patient nor does it warrant occlusion treatment. There is no evidence of an ocular motor dysfunction that was likely to benefit from vision therapy. Thus, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested inpatient hospital services for treatment of her methicillin-resistant staphylococcus aureus gastroenteritis, persistent nausea, vomiting and diarrhea, liver cirrhosis, portal hypertension, large splenomegaly, pancytopenia, B12 deficiency, folate deficiency, iron deficiency, chronic pain syndrome and gallstones without evidence for cholecystitis.  Findings:  The physician reviewer found that the patient has advanced chronic liver disease. She underwent a colonoscopy on the date in question. She received substantial doses of a narcotic (Demerol) and a benzodiazepine (midazolam) for sedation-analgesia for colonoscopy. The combination of these medications, a narcotic and a benzodiazepine, results in profound amnesia that can be an anterograde amnesia even after what appears to have been full recovery and awakening from the effects of sedation-analgesia. These effects will be more pronounced and more prolonged in a patient with chronic liver disease than in an otherwise healthy patient without chronic liver disease. Because of the doses of narcotic and benzodiazepine used in this case, it was medically necessary to keep this particular patient overnight to insure that the drugs administered were metabolized sufficiently to permit safe discharge.  Hospital discharge before the effects of the narcotic and benzodiazepine wore off could have placed her at risk of harm.  All told, inpatient hospital services provided during this time were medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast screening mammogram. Findings:  Two physician reviewers found that the report revealed fatty tissue but no evidence of malignancy was noted. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone.  Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been performed using two dimensional imaging alone. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. Menter and colleagues note that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab (brand name Taltz) as a monotherapy treatment option in adult patients with erythrodermic psoriasis. In this case, the patient has a relatively new onset psoriasis on the extremities that has not responded to topical steroids or Enbrel. The patient has a history of deep vein thrombosis and daily alcohol intake, and resides in an area endemic to coccidiomycosis, a fungal infection. Given that the patient has a diagnosis of psoriasis and reports good response to Taltz, the requested medication is medically indicated. Therefore, Taltz is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee requested occupational therapy at the frequency of one hour per week for medical treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found thatan occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. this case, the in-Plan occupational evaluation noted that the patient had some sensory issues and his activities of daily living were not a concern. However, the evaluator did not assess fine motor skills and gross motor skills. Evaluation of the patients fine and gross motor skills is needed in order to determine whether occupational therapy is clinically indicated. If, upon completion of a complete occupational therapy evaluation deficits in fine and gross motor skills are found then a course of occupational therapy would be considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein ablation. Findings:  The physician reviewer found that the documentation does not support the medical necessity of the requested vein ablation. Most significantly, there is documented competence of the left SSV, which does not support an indication for ablation. Additionally, the patient has multiple risk factors for lower extremity arterial disease including severe coronary artery disease and atrial fibrillation with atrial thrombus. Overall, it is not clear that the patients symptoms are due to her varicose veins. Although mentioned by the patient, the records do not document varicose bleeding, which would be an indication for treatment with thorough assessment of arterial perfusion and direct treatment of the involved vein, not ablation of a competent vein. All told, the records provided for review do not demonstrate that the requested vein ablation is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 surgery with sub-specialty certification in vascular 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

A 61-year-old female enrollee has requested a hospital bed for treatment of her collapse of the posterior calcaneus along the posterior subtalar joint.  Findings:  The physician reviewer found that this patient sustained a severe calcaneal fracture that required surgery and will need revisional surgery. The initial surgery required hospitalization and transfer to a skilled nursing facility for rehabilitation. The patient received physical therapy and this was continued on an outpatient basis. Although the patient had prior hip replacement surgery, she was evaluated to be strong enough to perform necessary functions including wheelchair transfers. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, a hospital bed is indicated when special positioning is necessary. There is no evidence that this patient requires special positioning that cannot be achieved in a regular bed using pillows or wedges. All told, the hospital bed at issue is not supported as medically necessary for treatment of this patients medical condition.