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

A 37-year-old female has requested bariatric surgery (Lap Band surgery) for treatment of her obesity. Findings:  The physician reviewer found that this patient has a BMI of 57.9. She has failed dietary efforts in the past, including numerous diets and medication. The patient completed a thorough multidisciplinary evaluation that did not reveal any obvious metabolic, dietary or behavioral barriers to surgery. She meets all standard guidelines for medical necessity of bariatric surgery, including the National Institutes of Health guidelines. Based upon the submitted documentation, medical clearance was obtained. In this patients case, the requested surgery is medically indicated.  The submitted documentation and current medical evidence support the medical necessity for the requested bariatric surgery (Lap Band surgery) in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization level of care for treatment of the enrollees behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was ruminative regarding suicidal ideation but without intent or plan.  Thus, her suicidal ideation was passive in nature.  She was not functionally impaired and did not have medical comorbidity.  Her psychiatric diagnoses were unchanged, as was her medication regimen, and she suffered no side effects.  Her recovery environment was moderately stressful in that she was still exposed to a social circle of friends who were active substance users.  The patients family participated in family sessions and her mother actively worked with her on her treatment plan.  She had a moderate response to treatment, and was beginning to recognize the need to develop internal motivation, recognize triggers, and avoid substance using friends and associated situations.  Overall, she no longer needed the structure of partial hospitalization program level of care.  All told, partial hospitalization level of care 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 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

A 21-year-old female enrollee has requested residential treatment services for her behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted for review, the patient is and has been at her baseline level of functioning for several years. The patient has longstanding chronic symptoms that are unwavering in nature. It is clear that when under stress the patient decompensates and develops suicidal ideation with an increase in anxiety. However, this is not the same as suicidal intent or suicidal attempts. There is no imminent risk to self harm and there is no indication that the psychosocial stressors are temporary and/or given to remit in the near future. In sum, the patient does not meet the medical necessity criteria for residential level of care services provided from the said date forward.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Foundation One gene test for evaluation of the enrollees recurrent glioblastoma. Findings:  The physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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

A 20-year-old male has requested coverage for Humira 40mg injections every week, rather than the approved dosage schedule of every other week for treatment of his ulcerative colitis.  Findings:  The physician reviewer found that Humira is FDA-approved for treatment of Crohn's Disease. While it generally is effective in inflammatory bowel diseases (Hoentjen, et al.; and Fiorino, et al.), it remains off-label for treatment of ulcerative colitis. A phase 3 trial is currently ongoing to evaluate treatment of ulcerative colitis with Humira, however, the results of this study have not yet been published. A recent study by Sandborn, et al. (Gastroenterology, 2011) indicates that in doses of 40mg every other week, `Adalimumab was safe and more effective than placebo in inducing and maintaining clinical remission in patients with moderate-to-severe ulcerative colitis who did not have an adequate response to conventional therapy with steroids or immunosuppressants.`Every other week dosing of off-label use Humira has been approved as a benefit for this patient with ulcerative colitis, and it is documented in the medical records that the patient has responded clinically to the agent.  However, there is a paucity of literature supporting the use of Humira 40mg at a weekly frequency.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested for Malarone pills for treatment of her medical condition. Findings:  The physician reviewer found that the current strategies employed to avoid contracting malarial infection when travelling to endemic areas include: the use of insect repellant sprays and liquids, bed netting, long pants and long sleeve shirts and chemoprophylaxis, before, during, and after leaving malarial areas. The Centers for Disease Control (CDC) recommended drugs for chemoprophylaxis of malaria include: Malarone (atovaquone/proguanil), doxycycline, chloroquine, mefloquine (Lariam), and primaquine. However, the latest information from the CDC relates that chloroquine is not a suitable anti-malarial agent for travel in Kenya at the present time due to the presence of drug-resistant strains. Malarone is usually very well tolerated with few serious side effects seen (see Berman and colleagues).From the clinical data provided and given the findings in the medical literature cited above, this patient did require chemoprophylaxis against malaria and the three drugs suitable for her for this trip included: Malarone, mefloquine (Lariam) and primaquine. However, Malarone was not medically necessary as this patient could have taken mefloquine (Lariam), which according to her Health Plan was a covered medication option on their list of formularies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for immunotherapy (once per week for 52 weeks (two sets)). The submitted documentation supports the medical necessity of a portion of the requested services. Allergen immunotherapy is defined as the repeated administration of allergen extracts to patients with allergic diseases for the long-term relief of symptoms. It has been demonstrated to be effective in immunoglobulin E (IgE) mediated diseases, particularly in patients with a limited number of allergies. Subcutaneous immunotherapy has been shown to be effective in patients with allergic rhinitis, as demonstrated by significantly decreased usage of allergy medications. Immunotherapy also has demonstrated efficacy in seasonal asthma. Most immunotherapy protocols are divided into an updosing phase, generally involving weekly injections for up to 16 weeks, followed by several (up to five) years of monthly injections. A more contemporary means of providing immunotherapy is via the sublingual route. For this patient with severe allergic rhinitis, moderate persistent asthma and environmental allergies, immunotherapy may provide some benefit. However, the current medical evidence does not support the medical necessity of the requested regimen of weekly injections for 52 weeks. Based on the literature, weekly injections for 16 weeks followed by monthly injections for maintenance is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics 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 immunotherapy combination of nivolumab (Opdivo) and ipilimumab (Yervoy).Per the National Comprehensive Cancer Network, for patients who experience disease control (complete response, partial response, or stable disease) and have no residual toxicity, but subsequently experience disease progression/relapse greater than three months after treatment discontinuation, re-induction with the same agent or same class of agents may be considered. In addition, although some studies show benefit of ipilimumab rechallenge, it is limited to those with an initial response. In this case, the patient had progression of disease on nivolumab and pembrolizumab. This patient does not fit criteria for rechallenge. Therefore, immunotherapy combination of nivolumab (Opdivo) and ipilimumab (Yervoy) is not medically necessary for 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for knee arthroscopy (CPT 29875, 29880, and 29877).Lamplot and Brophy concluded, Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Ji and colleagues indicate, Positive McMurray sign implies good postoperative outcomes for the patients with meniscal tear associated with osteoarthritis. For patients with osteoarthritis, those whose positive McMurray signs are in line with their radiological findings indicate they are eligible candidates for arthroscopic meniscectomy. Our study suggests that McMurray sign can be used as an indication for both symptomatic meniscal tear and postoperative outcomes. Finally, Mezhov and colleagues found, First-line trial of conservative therapy is recommended for the treatment of degenerative meniscal tears in older adults. The exception to this may be when mechanical symptoms, such as knee locking, predominate.In this case, the patient sustained a fall injury to her right knee. The patient is noted to have osteoarthritic findings on imaging. There was no detailed indication of recent, comprehensive and reasonable conservative treatment provided to this patient for her knee pain beyond medication and crutches. Additionally, there are no mechanical symptoms (locking, giving way) clearly arising from the meniscal tear. There is no documentation of orthopedic testing, including McMurrays test, to document internal derangement. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines. Therefore, the requested knee arthroscopy is not medically necessary for treatment of the 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 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: Upheld

The parent of a five-year-old male enrollee requested social skills group therapy (nine hours per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient is currently receiving 10 hours per week of ABA therapy. The Health Plan has recommended the patient work with his ABA provider to address his social deficits. Given the lack of support in the medical literature demonstrating the efficacy of social group therapies for autistic children with social deficits, the Health Plans recommendation is reasonable and appropriate to treat the patients social deficits. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injections and stem cell injections.Findings:  Two of the three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The records document plantar plate tears and osteoarthritic changes to the first metatarsophalangeal joint. Currently, most of the studies on platelet-rich plasma and stem cell injections have been performed for the treatment of lateral epicondylitis. At this time, platelet-rich plasma injections and stem cell injections are not considered standard of care in this patients case. The standard of care treatments for plantar plate tears include immobilization, non-weight-bearing, physical therapy, and surgical plantar plate repair. Therefore, the requested platelet-rich plasma injections and stem cell injections are not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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

A 45-year-old enrollee who has been diagnosed with focal partial idiopathic epilepsy and hyponatremia. An electroencephalogram (EEG) in 2020 was noted to be abnormal with frequent right frontal and bifrontal epileptiform discharges. In June 2020, the provider noted that the patients sodium level was 130 mEq/L, and a switch from the medication Oxtellar to Aptiom was recommended due to the patients high frontal activity. The provider noted that the patient had one seizure in March 2020. The patient has requested authorization and coverage for Aptiom 800 mg tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient.  At issue in this case is whether Aptiom 800 mg tablets are medically necessary for the treatment of the patients medical condition. Medical literature reported, Eslicarbazepine acetate (ESL), is a once-daily, oral antiepileptic drug (AED) for the treatment of focal (partial) onset seizures in patients four years of age or older. ESL is a member of the dibenzazepine carboxamide class of putative voltage-gated sodium channel blocking AEDs, which also includes carbamazepine and oxcarbazepine. Hyponatremia (i.e., low blood sodium) may occur with the used of dibenzazepine carboxamide AEDs. Researchers  reported, Carbamazepine and oxcarbazepine are the most common AEDs which induce hyponatremia in patients with epilepsy. Recently, other AEDs, such as eslicarbazepine, sodium valproate, lamotrigine, levetiracetam and gabapentin have also been reported to cause hyponatremia. In this case, the provider recommended a switched from the medication oxcarbazepine (Oxtellar) to eslicarbazepine (Aptiom) for the treatment of the patients focal partial idiopathic epilepsy. The patient has also been diagnosed with hyponatremia. The providers rationale for switching from Oxtellar to Aptiom appears to be related to the patients hyponatremia. However, both medications are known to cause hyponatremia. As such, the patient is not likely to benefit from this medication change. The medical evidence does not support the requested medication in this clinical setting. Therefore, Aptiom 800 mg tablets are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 3D digital x-ray of the breast (tomosynthesis) for evaluation of her palpable mass in the left breast.  Two physician reviewers found that this patient had bilateral silicone implants which make the breasts difficult to position and image in their entirety using conventional mammographic views. Usually the presence of a palpable mass is approached by standard mammography and ultrasound to follow. One advantage of tomosynthesis in this clinical setting is the ability to image the entire breast without significant or exaggerated compression. Also, the technique is valuable in the examination of the contralateral, asymptomatic breast for occult mass. The use of tomosynthesis in addition to standard digital mammography has gained acceptance in the past few years due to the preliminary experience of decreased callbacks and increased detection of small cancers. Thus, the 3D digital x-ray of the breast (tomosynthesis) was likely to have been more beneficial for evaluation of this patients palpable breast mass, the remainder of the symptomatic left breast, and the entire contralateral right breast, than any available modality. Final Result: Two reviewers determined that the services at issue were 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 board certified in diagnostic radiology 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 58-year-old female with hip pain. Radiographs have been obtained which reveal significant arthritis of the hip. A request has been made for an MRI to further evaluate the patients hip. The Health Plan has denied this request on the basis that an MRI will not impact the patients treatment because the only treatment for the patient is hip replacement.The Health Plans denial is correct. The patients radiographs reveal significant osteoarthritis. Treatment for this patients condition is hip replacement. Because a diagnosis has been established, an MRI is not indicated. An MRI will not add any new or important information that is not already known. Regardless of the MRI results the patient has severe osteoarthritis and would benefit from hip replacement. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for custom molded orthotics (shoe inserts) provided. Findings:  The physician reviewer found that the current guidelines and medical literature do not provide adequate evidence to support the medical necessity of the custom made orthoses for treatment of this patients medical condition. Inserts and other shoe modifications such as arch supports are considered medically necessary if they are on a shoe that is an integral part of a necessary leg brace, if they are needed for the proper functioning of the brace. Orthopedic and podiatric literature does not substantiate the need for custom molded orthoses for this particular patient. All told, the custom molded orthotics (shoe inserts) provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the equipment at issue was 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 podiatry 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.