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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. This patients clinical course and presentation are consistent with mild constitutional delay of growth and development based on normal growth velocity, height, insulin like growth factor binding protein 3 (IGFBP-3) level, bone age with a positive family history for constitutional delay. Although the patients peak circulating growth hormone of 9 ng/mL was below the cutoff value of 10 ng/mL for classic growth hormone deficiency and one insulin like growth factor 1 (IGF-1) value was documented as low, the patient does not meet the criteria for growth hormone deficiency based on normal growth velocity, normal height, normal IGFBP-3 level, and normal bone age. Since puberty has recently begun based on testicular volume of 4 mL, pubertal steroids have not likely been a major stimulus to growth. Direct measurements of parental heights may revise the midparental target height closer to the predicted adult height. Based on the available documentation the patient does not meet U.S. Food and Drug Administration (FDA) approved criteria for somatotropin therapy. The patient's height is above -2.25 standard deviations (SDs) below the mean, which does not meet key diagnostic criteria for idiopathic short stature. All told, the requested Nutropin AQ Nuspin 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 pediatrics with subspecialty certification in pediatric endocrinology 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 37-year-old male enrollee has requested Onfi (clobazam) for treatment of his intractable epilepsy. Findings:  Three physician reviewers found that Onfi is likely to be more beneficial for treatment of the patients medical condition than other options.  There is sufficient evidence in the peer-reviewed literature that supports clobazam as safe and effective for the treatment of seizure types not associated with Lennox-Gastaut syndrome. Clobazam has been shown in multiple studies to be an effective drug for the treatment of both refractory complex partial seizures and tonic clonic seizures. Finally, this patient has tried and failed at least 4 anticonvulsants, thus Onfi is likely to be more beneficial than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with a long-standing history of alcohol dependence and depression, drinking approximately two bottles of wine and four vodka mixed drinks each night for the past two and a half years, to the point of blacking out every night for the three months prior to admission to residential treatment on 7/27/04. The patient related the increased drinking to an increasing level of depression, which was related to a series of losses. These included her mothers decline and death from Alzheimers disease, loss of some friends, an extremely stressful job, and living by herself. She was previously treated on an outpatient basis with Paxil 20mg with little perceived benefit. Pertinent social history otherwise included her emanating from a family in which her father was strongly alcohol dependent, and the patient having been married and divorced three times, with no children, and no longer involved in any intimate relationship. Upon admission to residential treatment, she was noted as depressed and affectively blunted. Her Paxil was increased to 40mg and trazodone was eventually added for sleep continuity disturbance. She was also treated with a number of therapies, appearing quite motivated for the program and without any particular withdrawal related symptoms. On 8/2/04, she was noted as affectively neutral and on 8/8/04, she conceded that she was very guarded all her life. On 8/13/04, her psychiatrist noted her as still anxious about not having a very detailed and concrete plan for her recovery.  However, by 8/15/04 she was noted as cheerful and bright and the remaining notes in her chart consistently point to her as such in mood and in affect. The patient remained in the chemical dependency treatment program until 8/27/04 and is seeking reimbursement for her stay. The Health Plan has denied coverage for chemical dependency treatment services from 7/31/04 through 8/27/04 indicating the patient could have been treated at a less intense level of care.The submitted records demonstrate the patients alcohol consumption was not only quite excessive on a daily basis for some years but was attendant with an increasing frequency of blackouts. All of this, superimposed on a highly avoidant character structure, would support the notion of her warranting residential treatment. Clearly, the patient did not have a great many immediate social supports to help her rein in her drinking and, in fact, she has tended to ward off connections with others. As such, outpatient treatment was not likely to be as effective as removing her from that environment, into one that was alcohol-free. As such, residential treatment was medically warranted. At the same time, the patient appears to have consistently brightened by 8/15/04 such that transfer thereafter to partial hospitalization would have been appropriate. Hence, I have determined that chemical dependency treatment services were medically necessary for treatment of the patients medical condition through 8/15/04. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the chest. Given this patients history of chronic symptoms, smoking, and occupational inhalational exposure, the American College of Radiology (ACR) supports a CT of the chest without contrast with high-resolution imaging. The bilateral upper lobe ground glass opacities on recent imaging are interstitial lung changes. A repeat CT would be helpful to evaluate resolution, progression, and other interstitial lung conditions not well depicted on chest radiography (Ferguson and Berkowitz). There is no need for use of intravenous (IV) contrast with the CT imaging. Given these findings, the requested CT scan of the chest is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for percutaneous arthrodesis of the sacroiliac (SI) joint. The Health Plan has denied the requested procedure as investigational for treatment of the enrollees SI joint dysfunction.Findings:  Two out of three physician reviewers found that SI joint degeneration is a common cause of chronic low back pain which is under-diagnosed. Minimally invasive fusion procedures have demonstrated successful pain relief for these patients. Recent medical literature has documented two-year follow-ups of these procedures, demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. The medical literature reports minimally invasive SI joint fusion using triangular titanium implants showed marked improvements in pain, disability and quality of life two years after fusion. One study noted that radiographic evidence of intra-articular fusion within the joint may take more than one year in many patients. In the absence of evidence of neural compression on MRI and in the presence of clinical findings of SI pain, which is relieved by injecting the SI joint, the requested procedure of SI fusion using the minimally invasive technique is likely to be successful in this patient. Thus, the requested percutaneous arthrodesis of the SI joint is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One physician reviewer found that overall, more research is needed to show the safety and efficacy of SI joint fusion. Long-term outcomes and complications remain ill-defined. Additionally, in this case, there is no documentation of SI joint instability, fracture or lesion.Final Result: Two out of three reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an additional four weeks of Harvoni for treatment of her 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) guidelines, all patients with chronic active hepatitis C virus are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. In treatment-naive genotype 1 patients, the guidelines recommended Harvoni for 12 weeks (Class I, Level A recommendation). This recommendation is based on randomized clinical trials. Consideration for 8-week therapy in patients with baseline viral load of less than 6 million IU/mL is based on post-hoc analysis of the ION-3 trial, resulting in an uncontrolled comparison.  The AASLD/IDSA guidelines indicate that these results are not generalizable. Based on the evidence of safety and efficacy in the published literature, and current clinical guidelines, the extension of Harvoni to 12 weeks (4 additional weeks) is considered medically necessary in this case. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

The patient is a 40-year-old male with chronic pain due to peripheral neuropathy. He is requesting Anodyne therapy (infrared) for treatment of his chronic pain. The Health Plan has denied the patients request indicating Anodyne therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Anodyne and other infrared therapy modalities have not been proven efficacious in peer-reviewed literature. Such therapies are not currently among the accepted standard of medical care for treatment of peripheral neuropathy pain. As such, there is insufficient evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities. Therefore, I have determined that 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the medication Xifaxan 550mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with diarrhea (IBS-D) and small intestinal bacterial overgrowth. The submitted documentation supports the medical necessity of the requested medication. In this case, the patient had both irritable bowel syndrome, diarrhea-predominant (IBS-D), and small intestinal bacterial overgrowth. The patient had failed both Lomotil and tetracycline. The formulary alternatives for IBS-D would not treat the patients bacterial overgrowth, and formulary alternative antibiotics are associated with adverse effects and would not treat the patients IBS-D. Under these circumstances, the Xifaxan 550mg tablets were medically necessary to treat the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Grafix PL placental allografts performed on four dates of service, as well as prospective authorization and coverage for 6 units of Grafix Prime and Grafix PL Prime. Findings: Two of the three physician reviewers found that the services at issue and requested services were not and are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While placental allografts do show promise for the treatment of diabetic foot ulcerations, most if not all of the studies on this type of allograft application are small. The studies advise that more research must be performed in order to demonstrate significant effectiveness of this type of allograft application beyond standard of care. Standard of care includes soft tissue and nonviable tissue debridement, scrupulous cleansing of the wound, antibiotics if necessary (topical and/or oral), and non-weight bearing and/or offloading of the ulcer site. Vascular status must also be assessed in order to demonstrate adequate blood flow for healing. In this case, the Grafix PL placental allograft has been utilized as a supplement to wound debridement and offloading of the ulcer site with the CROW boot. Under these circumstances, the applications of the Grafix PL allograft were not more beneficial than standard of care. In addition, the prospective use of 6 units of Grafix Prime and Grafix PL Prime is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services at issue and requested services were not and are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:All three reviewers are board certified in podiatry 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine infusion for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the documentation available for review, there is reference to failure of multiple standard treatments of pain. However, not all non-opioid medications classes have been optimized or tried. There is no evidence that other anticonvulsant medications or antidepressants have been failed or are contraindicated. Also, the patient may respond to maintenance therapy at a higher dose of Cymbalta. In addition, there is no mention of recent physical therapy and a home exercise program. Further, while it is noted the patient had subjective relief from the ketamine infusion, no objective functional improvement is documented. With regard to the medical literature, the effectiveness of ketamine infusions for post laminectomy syndrome is lacking. Current data suggest that ketamine infusion response lasts about three weeks for back pain and is not a long-term treatment strategy. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential level of care services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue.  The medical records failed to demonstrate that less restrictive interventions targeting her substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  Considering the patients clinical presentation and treatment history, there is a lack of evidence suggesting that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming with therapeutic inclusion of marital counseling and community-based peer support and sponsorship, would have been unreasonable or consistent with inadequate care.  Thus, residential treatment center services were not medically necessary 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Psychiatric Intensive Outpatient Program (IOP) services.In this case, in terms of risk of harm, the records support a score of 3, which corresponds with a significant risk of harm. This is due to the patient's impulsivity, destruction of property, aggression, and recent substance abuse. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patients conflict with his mother, his defiant behavior with IOP staff, as well as his maintenance of abstinence from substances while enrolled in the IOP program. In terms of comorbidity, the records support a score of 3. With regards to the level of stress of the recovery environment, the records support a score of 3 In terms of the level of support of the recovery environment, the records support a score of 2, as the patients mother actively participated in treatment, thereby providing a supportive environment. With regards to resiliency and treatment history, the records support a score of 4, which reflects poor resiliency and response to treatment. In terms of acceptance and engagement of the patient, the records support a score of 3. Thus, the patient had a composite score of 21. Using the CALOCUS level of care determination decision tree, the recommended level of care is Level Four: Medically Monitored Community-Based Services. As the current program offers wrap-around services, including 24-hour crisis support, it is consistent with this level of care. Therefore, the Psychiatric Intensive Outpatient Program (IOP) services at issue and going forward were and are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services 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 subspecialty 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 patient is a nine-year-old female who demonstrates difficulty in producing /s/ sounds. Past medical history is significant for multiple sinus infections, although no medical documentation of the infections has been provided. The therapist documents a normal birth history and motor development. The patient has no history of feeding, chewing or swallowing difficulties. Oral motor skills were within normal limits. The therapist also reports a normal hearing screen. Language is within normal limits, but the patient has difficulty with lateralization of the /s/, /z/ and /s/ blends. Speech intelligibility is at the 80% level for the average listener. At issue is whether speech therapy provided from February 2004 through March 2005 was medically necessary.Review of the medical literature reveals no evidence to support the contention that sinus infection can be related to chronic articulation abnormalities. With no medical reports documenting the history of significant chronic sinusitis and no medical literature supporting the supposition that the sinusitis caused the misarticulation, there is no evidence the misarticulation has a medical cause. Since no disease or other medical cause has been established, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.