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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone 20 mg, one to two every four hours for a total of 240 per month. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. In the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested oxycodone 20 mg, one to two every four hours for a total of 240 per month is not supported as medically necessary for treatment of this patients chronic pain. 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 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: The parent of an enrollee has requested authorization and coverage for Genotropin injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees Idiopathic Short Stature. According to the Pediatric Endocrinology Society 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 (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 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. In this case, based upon the data provided, the patient does not satisfy the above criteria. While the patients height is more than 2.25 standard deviations (SDs) below the mean for his age and gender, and his growth velocity is poor, there is no documentation of a recent pubertal exam or bone age. There is also no documentation that all other causes of growth fall-off have been ruled out. The FDA has approved GH therapy for children with short stature who are predicted to reach an adult height of <63 inches in males and <59 inches in females, but without information on a recent bone age examination, an up-to-date estimation of final adult height cannot be made. Updated information on pubertal examination, lab data ruling out other causes of short stature, and a bone age assessment, are needed to determine the medical necessity of GH administration. Accordingly, Genotropin injections are not medically necessary for treatment of the enrollees medical condition at this time.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty 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: The patient has requested authorization and coverage for a supervised sleep study in a lab. Findings:  The physician reviewer found that records provided for review document that this patient presents with sleep maintenance insomnia primarily secondary to obstructive sleep apnea (OSA). The patient could also have periodic limb movement disorder as a contributing factor to her insomnia. As the patient is symptomatic and has moderate OSA, treatment with continuous positive airway pressure (CPAP) therapy is appropriate. The American Academy of Sleep Medicine (AASM) recommends in-lab titration of CPAP in this clinical setting. However, the requested diagnostic supervised sleep study to be performed in a lab is not indicated as the patient was already diagnosed with OSA and additional testing will not add to her management. Therefore, the requested supervised sleep study in a lab is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in sleep 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 reimbursement for the residential treatment center (RTC) level of care services for treatment of the enrollees opiate use disorder. Findings:  The physician reviewer found that this patients post-acute withdrawal symptoms were not described other than his cravings and moods. There was no evidence that he was a danger to self or others. He was cognitively intact, and his level of emotional and behavioral issues were not severe enough to warrant ongoing RTC services. He demonstrated inappropriate behavior in group therapy. However, he was not manic, psychotic, or agitated. He was medically stable. He continuously expressed that he lacked interest in pursuing sobriety and relapse prevention. He was discharged on Suboxone, of which the management did not require the RTC setting. Given the patients lack of motivation and distinct, well-defined, and verbalized intent to resume drinking and use cannabis, the RTC services were not medically necessary for treatment of the patients medical condition. 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 addiction 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 treatment center (RTC) services for treatment of the enrollees alcohol dependence. Findings: The physician reviewer found that the records document that this patient had no post-acute withdrawal symptoms, although he continued to experience cravings. The patient was not a danger to himself or others. Although initially medically unstable, the patient was deemed to be medically stable and not in need of 24-hour care. Moreover, he was psychiatrically stable. The depression he was experiencing did not need to be managed at the RTC level of care. There were no emotional, behavioral, or acute cognitive conditions that warranted RTC treatment. He had improved cognitively, he was motivated, insightful, and appeared to be working the program. Although he continued to struggle with his emotions and required further treatment to help develop and solidify coping skills, this did not require the structured environment of a RTC setting and could have continued at a lower level of care. For these reasons, the RTC services provided were not medically necessary for treatment of this patients medical condition.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 addiction 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has enrollee has requested authorization and coverage for a hypoglossal nerve neurostimulator. The records provided for review document that the patient has obstructive sleep apnea (OSA). A patient case summary reported that the patient had a body mass index (BMI) of 21.87 and his apnea/hypopnea index (AHI) was 18.9. The summary noted that a drug-induced sleep endoscopy (DISE) showed anterior posterior collapse. In a letter, the provider noted that the sleep endoscopy confirmed that the patient did not have complete concentric collapse of the upper airway. The patient was unable to tolerate a CPAP or dental device. The U.S. Food and Drug Administration (FDA) has approved the Inspire device for the treatment of OSA. Given the patients intolerance to CPAP therapy, anterior posterior collapse, no central apnea, and BMI and AHI within FDA criteria, the patient is a candidate for the Inspire device. Therefore, the requested hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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 reimbursement for coronary angioplasty provided by Mayo Clinic Arizona on 1/08/21.The current medical evidence supports the service at issue in this clinical setting. Patel and colleagues indicate that diagnostic cardiac catheterization is considered appropriate in both symptomatic and asymptomatic patients with positive stress echocardiogram findings of stress-induced wall motion abnormality in two or more segments. In this case, the patient had exercise-induced hypokinesis of the anterior and septal segments, suggesting possible proximal left anterior descending artery obstructive disease. Therefore, the coronary angioplasty provided by Mayo Clinic Arizona on 1/08/21 was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous immune globulin for treatment of his status post kidney transplant.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The records do not indicate that a recent biopsy has been performed, and a biopsy is recommended in all patients who develop donor specific antigens.  Donor specific antigens in patients with stable renal function and no antibody-mediated rejection by biopsy do not adversely affect long-term graft survival.  In this patients case, donor specific antigens may have developed when immunosuppression was reduced.  Since this patient is not likely to be highly sensitized, the donor specific antigens have developed after the first year, and allograft function is stable, the medical evidence supports a transplant biopsy prior to consideration of intravenous immune globulin.  All told, the requested intravenous immune globulin is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy 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 nephrology 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

The patient is a 66-year-old female with symptomatic collagenous colitis. She had been treated with 5-ASA products and prednisone, but due to side effects prednisone was discontinued. She was started on Entocort and has had good results. The Health Plan has determined Entocort is not medically indicated for treatment of the patients medical condition. Though the FDA indication for Entocort is for treatment of mild to moderate active Crohns disease involving the ileum and/or the ascending colon, there are numerous published studies in the medical literature regarding the safety and efficacy of Entocort for treatment of collagenous colitis. The patient has failed conventional treatment for this disease. The submitted clinical information documents that she has had good results with Entocort without adverse side effects. As such, continued use of Entocort is medically reasonable and indicated for treatment of the patients collagenous colitis. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center (RTC) services for treatment of her behavioral health condition.  Findings: The physician reviewer found that the submitted documentation does not indicate that the patient was at imminent risk of harming herself or others during the period at issue. The patient's symptoms could have been effectively treated in a less intensive setting. She was medically stable and did not evidence need of a 24-hour level of care. Moreover, as detailed above, the records indicate that the patient presented with a chronicity of symptoms throughout her residential stay and was not at imminent risk of relapse or worsening symptoms during this period. In the discharge note it was stated that the patient had not made progress regarding reducing her suicide ideations; however, she was deemed stable for discharge to an outpatient level of care. Based upon these findings, the RTC services were not medically necessary for treatment of the patients behavioral health condition.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 patient has requested authorization and coverage for Harvoni 90-400 mg tablets once daily for eight weeks for treatment of hepatitis C. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommends treatment for all patients diagnosed with chronic hepatitis C virus (HCV) infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. One study reported that since 2013, all-oral, interferon-free regimens with direct-acting antivirals have quickly become the mainstay of treatment for HCV infection as they provide high rates of sustained virologic response with a relatively short duration of treatment and low side effect profile. In this case, the patient was diagnosed with hepatitis C with a Metavir score of F0-F1. The medical evidence supports the requested medication in this clinical setting. Therefore, Harvoni 90-400 mg tablets once daily for eight weeks are 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 internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the immune cell functional assay (ImmuKnow) for evaluation of the enrollees Stage V chronic kidney disease secondary to lupus nephritis status post kidney transplant.   Findings:  The physician reviewers found that The ImmuKnow assay is a U.S. Food and Drug Administration (FDA) approved test that has been used as an adjunct for immune monitoring after transplant. The ImmuKnow assay was used by this patients provider as part of the protocol for its labelled indication as described on its FDA label. Combined with other biomarkers can be used to identify kidney transplant patients at high risk of rejection and infection. Further, the Centers for Medicare and Medicaid Services (CMS) support the utility of the ImmuKnow assay for use in this clinical setting. All told, the peer-reviewed medical literature and current guidelines support the immune cell functional assay (ImmuKnow) was 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 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 number one, two, and three are board certified in surgery and critical care surgery 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.