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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested the Growth Hormone (GH) therapy medication Humatrope 12 mg cartridge for treatment of the enrollees short stature. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has extreme short stature and normal weight for height ratio, with an adult predicted height that is three standard deviations (SD) below the mean for adult standards in the United States. Although he has had normal growth factors, and GH stimulation testing has not been performed, this patient meets the Pediatric Endocrinology Society (PES) guidelines (Gharib, et al; Wilson, et al). Per PES guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two SD below the mid-parental height percentile; (2) growth velocity less than the  25th percentile for bone age; (3) bone age more than two  SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least three of the above criteria. Therefore, the requested Humatrope 12 mg cartridge 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 pediatrics with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rabeprazole. Findings:  The physician reviewer found that : the documentation provided does not support the medical necessity for the requested medication in this clinical setting. American College of Gastroenterology guidelines recommend twice-daily therapy when once-daily therapy is insufficient to control gastroesophageal reflux disease symptoms, including in patients with esophagitis .  The medical literature does not show any difference between rabeprazole and most other proton pump inhibitors (including pantoprazole, omeprazole, and lansoprazole) for gastroesophageal reflux disease or esophagitis. As such, it is unlikely that trial of formulary alternatives will be helpful after the patient has failed omeprazole and esomeprazole .  However, this patient has not attempted Dexilant.  Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. A study  notes that this delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. A significant majority of patients (88%) on other proton pump inhibitors twice daily were able to control symptoms on Dexilant once daily . Other medical studies have shown that Dexilant is also more effective to treat symptoms than alternatives such as esomeprazole .  For these reasons, rabeprazole is not supported as 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 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: Experimental/Investigational
Decision: Overturned

A 35-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that this patient has chronic migraines and has failed five preventive therapies. Beta-blockers are contraindicated given her history of asthma. Botox has been very helpful for her headaches in the past. Botox has been shown in studies in peer-reviewed journals to reduce the frequency and severity of chronic headaches. The patient has a history consistent with disabling chronic migraine. There are no FDA approved treatments for chronic migraine. She has tried and failed standard episodic migraine preventive therapy. Unmanaged, her headaches are severely disabling, and would require ongoing and potentially hazardous daily treatment with narcotics and triptans. Botox has variable, though considerable data consistent with a positive benefit as a migraine preventive, especially when the frequency of attacks is high (chronic migraine). She has been treated with Botox for multiple cycles with substantial success.  With Botox, she has had a reduction of headaches, improvement in response to acute treatment, and better ability to function. Botox has been more successful than standard preventive treatments for this patient. Prior Botox treatments should be covered by the Health Plan, and Botox should be approved for ongoing headache prevention.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested for skilled nursing facility (SNF) services for treatment of her fractured right ankle.  Findings:  The physician reviewer found that without continued daily skilled PT/OT, she may decline in strength and function by the time weight bearing as tolerated (WBAT) is allowed. Medicare guidelines allow continued daily skilled PT services when they are required to prevent or minimize deterioration.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Korlym 300 mg tablets. Korlym is a glucocorticoid receptor antagonist approved by the U.S. Food and Drug Administration (FDA) for use in Cushings syndrome to control hyperglycemia in patients who are not surgical candidates. In this case, the diagnosis of Cushings syndrome has not been established. The patient has features suggestive of Cushings syndrome, but none of the signs or symptoms are characteristic of the syndrome. The patient is obese, she is under stress, and she has a diagnosis of major depression. The medical records showed no cortisol level results to support the presence of hypercortisolemia. There are two overnight dexamethasone tests with normal suppressed cortisol, adrenocorticotropic hormone (ACTH), and nighttime salivary cortisol. A computed tomography (CT) of the adrenals was normal without evidence of adenoma and the patient has normal prolactin levels. Given these findings, the patient does not meet the diagnostic criteria for endogenous Cushings syndrome. Accordingly, the requested Korlym 300 mg tablets are 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 certification in diabetes, endocrinology, and metabolism 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 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.Analysis and Findings:While the patient entered partial hospitalization to better contain her overeating and anxiety, she had a rather protracted course of such treatment for a multitude of problems that are often treated with no more intensive therapy than outpatient care. In any event, the submitted records indicate the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating. There is nothing in the submitted records to indicate the patient warranted partial hospitalization beyond 5/12/04. There is no evidence that as of 5/12/04 the patient was experiencing any particularly acute problems. Outpatient treatment services as recommended by the Health Plan are medically reasonable and appropriate for the ongoing care of this patient. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Monosvisc Injection for the right knee. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees right knee osteoarthritis.The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. In addition, A reported on a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested Monovisc injection of the right knee is medically necessary for treatment of this patients right knee osteoarthritis. Final Result: The reviewer determined that the requested service 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 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 patient has requested authorization and coverage for brand name medication Lamictal XR (300 mg twice a day). In a retrospective study, Medical literatures reported that in previously seizure-free patients, switching the manufacturer of antiepileptic medications was associated with a higher risk for seizure recurrence. The authors concluded, It would be prudent to avoid switching the manufacturer of anticonvulsants in seizure-free patients. The Commission on Human Medicines guidelines on switching formulations of antiepileptic drugs notes, Patients with highly labile seizure control or optimal seizure control (i.e. seizure free or their seizure frequency has been markedly reduced) should not be switched to generics and should be maintained on their usual brand version for their antiepileptic drugs therapy. In this case, the records note that the patients seizures have been controlled on the brand name Lamictal and that she has previously tried and failed the generic formulation. In this clinical setting, given that current medical literature recommends against patients with controlled seizures being switched to the generic formulation of antiepileptic drugs, the requested medication is indicated. Therefore, brand name medication Lamictal XR (300 mg twice a day) 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The American Society of Addiction Medication (ASAM) criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting. In this patients case, the provided documentation for continued admission at the residential facility does not support the medical necessity for the services at issue. Recent documentation does not note the patient had suicidal or homicidal ideation, aggression, self injurious behavior, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. The records also do not contain reports of the patient having active withdrawal symptoms, unstable vital signs, lack of motivation to change, continued substance use, a dangerous or non-supportive recovery environment, or lack of access to effective care, all of which would support treatment at the residential level of care. Based on the clinical documentation provided and current medical literature, the residential treatment services were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined the services at issue were not and 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 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for dynamic pelvic floor magnetic resonance imaging (MRI) defecography (CPT 72195).Findings: Two out of three physician reviewers found that the authorization and coverage for dynamic pelvic floor MRI defecography (CPT 72195) is not likely to be more beneficial for the enrollee than any available standard therapy.Anal manometry quantifies the rectal and anal pressure changes during attempted defecation and reflex changes during balloon distention and thereby identifies dyssynergic defecation (DD). Anorectal manometry with rectal sensory testing is the preferred method for diagnosis of DD and abnormal rectal sensation. Newer tests, such as high-definition anal manometry, may provide better understanding through three-dimensional and topographic mapping. Evolving tools such as motor evoked potentials may provide comprehensive neurophysiological information. Defecography is useful in patients with suspected rectal prolapse or poor rectal evacuation. The balloon expulsion test can confirm impaired evacuation, but by itself is not diagnostic. All of these tests are in the armamentarium of gastroenterologists and colorectal surgeons to evaluate defecatory disorders. MRI defecography is not superior to the aforementioned battery of tests listed. Studies do not demonstrate that MRI defecography is superior to the aforementioned battery of tests listed. Thus, dynamic pelvic floor MRI defecography (CPT 72195) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested out-of-country rehabilitation services for urgent care of his post brain hemorrhage. Findings:  The physician reviewer found that there is no indication in the medical records demonstrating that the patient was unsafe for travel as of the period in question. There is clear evidence he had the endurance to be in a wheelchair for extended periods of time, i.e., at least eight hours. The patient was able to travel with supplemental oxygen. He was medically stable for transfer and had coherent speech. His injury was not a contraindication to air travel. Nor was the nature of the rehabilitation services urgent. The submitted records demonstrate the patient was able to travel to the in-plan service area and the services could have been delayed until the patient reached the in-plan service area.
Appeal type: Urgent Care
Decision: Upheld

A 26-year-old female enrollee has requested for emergency services. Findings:  The physician reviewer found that the prudent layperson standard defines an emergency as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had symptoms of an earache, congestion, and a sore on her lip for one week. Herpes labialis is a viral infection generally easily treated with supportive measures. Her symptoms were not acute in onset.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested for selective internal radiation therapy (SIRT) using yttrium-90 microspheres for treatment of his small bowel neuroendocrine tumor with metastases to the liver.  Findings:  Three physician reviewers found that the study by Kennedy and colleagues demonstrated that 86% of the entire group of patients demonstrated control of liver disease with SIRT therapy with Y-90 microspheres and 67% of the patients had no grade III or IV toxicities. The study by King and colleagues showed radiologic response in 50% of patients. The study by Rhee and colleagues concluded that over 90% of the patients had partial response or stable disease. This study showed that SIRT of metastatic neuroendocrine tumor is a viable therapy with acceptable toxicity. The study by Lim and colleagues indicated that overall treatment compared to toxicity was acceptable. In sum, the studies suggest that SIRT is a useful option for treatment of patients with multiple liver metastases from neuroendocrine tumor.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for high definition 3.0 Tesla magnetic resonance imaging (MRI) scans of the brain and skull/orbits for evaluation of her medical condition. Findings:  The physician reviewer found that while a 3.0 Tesla magnet scan would likely provide excellent images, it is also expected that excellent images can be achieved with a 1.5 Tesla magnet. 1.5 Tesla magnets are the general standard of care for excellent images throughout the United States.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested magnetic resonance imaging (MRI) of the pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the diagnostic procedure at issue. Endometriosis is a chronic gynecological disorder whose principal manifestations are chronic pain and infertility. The pain associated with endometriosis may not correlate with the stage of the disease, but there may be some associations with the depth of infiltration of endometrial lesions. Painful defecation during menses and severe dyspareunia are the most predictable symptoms of deeply infiltrating endometriosis (Fauconnier, et al). According to the medical records submitted for review, the patient does not complain of these symptoms. In addition, the diagnosis of endometriosis can only be made by the histology of lesions removed at surgery and neither serum markers nor imaging studies have been able to supplant diagnostic laparoscopy for the diagnosis of endometriosis or the extent of the disease (Practice No.114). MRI should be reserved for equivocal ultrasound results in cases of rectovaginal or bladder endometriosis (Practice Bulletin No.114). All told, the medical necessity of the diagnostic procedure at issue has not been established in this clinical setting.