Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  Two of the three physician reviewers found the data supports the short-term and long-term benefits of bronchial thermoplasty for select patients. In this case, the patient has allergic asthma that appears to be only partially controlled. He is on an aggressive regimen, but this is ultimately incomplete. Prior to pursuing bronchial thermoplasty, a trial of an anti-muscarinic agent is appropriate. These medications have been demonstrated to be efficacious in the management of asthma in this setting. The data supporting the efficacy of biologics in asthma is strong, and the records do not document that the patient exhausted this line of treatment. Further, he may also benefit from low-dose intermittent azithromycin to improve control of his asthma. In sum, bronchial thermoplasty is not likely to be of greater benefit than 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage brand name medications Norco 10/325 mg tablets or brand name Vicodin tablets (Vicodin-HP and Vicodin ES formulations). According to the U.S. Food and Drug Administration (FDA), generic drugs are created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand-name version. The FDA statement on generic drugs states that there is no difference in strength, quality or performance between generic and brand name medications. Further, generic medications have the same risks and benefits as brand name medications, and this would include any adverse drug reactions, such as hives. In this case, the patient reports that the generic formulations of Norco and Vicodin cause hives and are ineffective, whereas prior treatment with the brand name formulations of these medications was successful. However, the documentation does not demonstrate that the patient is intolerant to the generic formulations of the requested medications. The providers notes state the patient has been taking brand name Norco at the dose of 5/325 mg, which was noted to be ineffective, but without any side effects. The provider also noted that the patients only known drug allergies are from Sulfa and Penicillin exposure. The patient was planned to discontinue Norco and switch to Vicodin 10/325 mg. The notes report the patient developed hives and found Norco ineffective. In addition, the notes from the previous clinic visits do not document that the provider attempted to increase the dose of generic hydrocodone to 10/325 mg to assess for an improvement in efficacy. Overall, the records fail to demonstrate that the requested brand name medications Norco 10/325 mg tablets or brand name Vicodin tablets (Vicodin-HP and Vicodin ES formulations) are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name medications 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 anesthesiology with subspecialty certification in pain management 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 reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care services provided from 3/12/19 through 3/15/19 and 3/26/19 through 4/18/19 and a 90-day PHP level of care program. The American Psychiatric Association (APA) recommends a higher level of care than outpatient for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The APA supports PHP level of care for patients who require structure, are cooperative and are partially motivated, but remain preoccupied with intrusive repetitive thoughts more than three hours per day. This patients records support a diagnosis of bulimia nervosa, alcohol use disorder, dysthymia, anxiety, and OCD. The patient was unable to maintain his sobriety in the outpatient setting prior to admission to PHP level of care. His lack of motivation post early discharge, lack of structure due to not working, and isolation supported an indication for PHP services. A lower level of care was not available with the provider with whom he had established rapport. Thus, continued PHP was appropriate. Given this patients comorbid substance use, eating and mood disorders, his relapse risks and risk of harm to self, PHP level of care services provided and a 90-day PHP level of care program, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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:  An enrollee has requested authorization and coverage for a Monovisc injection in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 options are clearly limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties for mild osteoarthritis. Therefore, Monovisc injection in both knees is medically necessary for the treatment of the patients medical condition.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 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

A 38-year-old female enrollee has requested Provigil for the treatment of her depression and post-traumatic stress disorder. Findings:  The physician reviewer found that the Food and Drug Administration approval of Provigil supports the use of the drug for the treatment of four conditions: 1) narcolepsy; 2) multiple sclerosis; 3) sleep apnea; and 4) shift-work sleep disorder. Neither depression nor PTSD is listed as an approved indication for treatment with Provigil. At this time, there is inadequate peer-reviewed evidence demonstrating the efficacy of Provigil for fatigue associated with depression or PTSD. The article by Frye, et al. submitted with this appeal studied the use of Provigil in bipolar disorder which is not one of the patients diagnosed conditions. All told, the medical necessity of Provigil in this setting has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 80 units subcutaneously twice a week. The records provided for review document that this patient presents with idiopathic nephrotic syndrome. The patients provider has recommended treatment with Acthar Gel since the patient has failed treatment with prednisone and Bactrim DS. The U.S. Food and Drug Administration (FDA) has approved Acthar Gel for the treatment of patients with idiopathic nephrotic syndrome. Chakraborty and colleagues found that Acthar Gel has resulted in remission in patients with immunosuppressive and steroid-resistant nephrotic syndrome. Madan and colleagues concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant NS [nephrotic syndrome] in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. This patient has failed conventional first-line treatment with prednisone and Bactrim DS. Therefore, the requested Acthar Gel 80 units subcutaneously twice a week is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Upheld

A 41-year-old female enrollee has requested laparoscopic gastric Lap-Band for treatment of her obesity. Findings:  The physician reviewer found that this patient does not meet the criteria set by the National Institutes of Health (NIH) for weight loss surgery. According to NIH criteria, weight loss surgery is indicated for patients with a body mass index (BMI) of 40 or more or a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, coronary heart disease, or severe sleep apnea. The submitted documentation does not demonstrate the patient has any serious obesity-related comorbidities as required in order for patients with a BMI of less than 40 to be considered for surgical intervention. With a BMI of 38.09 and no serious comorbidities, the patient does not meet nationally accepted criteria for weight loss surgery. Further attempts at conservative management are more appropriate than surgical intervention in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her mastalgia.   Findings:  The physician reviewer found that the most recent American College of Radiology (ACR) practice guidelines for the performance of breast MRI outline 12 indications for dynamic contrast-enhanced breast MRI, and this patients records do not include evidence of any of these indications. Thus, evaluation with a mammogram should be performed to determine if further imaging with breast MRI as an adjunct is clinically indicated. However, based on the available documentation, the requested bilateral breast MRI is not medically necessary for evaluation of this patients breast tenderness.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Transderm-Scop 1.5 mg patches.  Findings:  The physician reviewer found that There is a lack of support for the requested medication in this clinical setting. Transderm-Scop 1.5 mg (scopolamine) is an anticholinergic medication that is U.S. Food and Drug Administration (FDA) approved for the prevention of nausea/vomiting associated with motion sickness and recovery from anesthesia and surgery. Motion sickness is a syndrome that occurs in response to real or perceived motion. Scopolamine patch and antihistamines are used for the treatment of motion sickness. Scopolamine is not considered more effective than antihistamine medications. In this case, the documentation does not support that the patient has been treated with formulary antihistamines. There is no documentation that these medications would not be effective for the patient, and she has not had any documented adverse effects to these medications. Therefore, Transderm-Scop 1.5 mg patches are not medically necessary for the 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 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: An enrollee has requested shoe inserts for treatment of her medical condition.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested equipment.  The progress notes indicate that this patient has left foot pain.  Overpronation for this patient is causing left foot pain as well as peroneal brevis tendinitis.  Orthotics will stabilize the medial and lateral column of the foot allowing for pain-free ambulation.  Furthermore, the patient has a limb length discrepancy which may cause knee and hip pain.  Compensating for this with a 5 mm elevation to the left orthotic is likely to alleviate this patients pain.  In sum, the requested shoe inserts are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested a custom knee brace and lightweight material for treatment of her torn anterior cruciate ligament. Findings:  The physician reviewer found that the requested brace is a functional brace that supports damaged ligaments. It is frequently used by individuals participating in sports after an injury. However, there is insufficient reliable evidence in the medical literature that supports the superior efficacy of this device in the postoperative period following ACL reconstruction in comparison to the use of a basic knee support such as a neoprene knee sleeve. Birmingham, et al. published the results of a clinical trial in 2008, concluding that, `A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.`  Subsequently, Andersson, et al. reviewed the literature and concluded that `the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction.` The specific features of the requested knee orthosis (i.e., a custom-fit, functional knee brace) are not medically necessary as there are no proven benefits of these features with respect to health or functional outcomes in the absence of anatomical abnormalities requiring custom fitting (e.g., extreme shortness, tallness, or obesity). No specific anatomical factors requiring custom fitting are documented in the present case. The requested device, therefore, is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 9-year-old male enrollee has requested occupational therapy (8 sessions, with a frequency and duration of 45 to 60 minutes per session over the next 8-10 weeks) for treatment of the enrollees lack of coordination and development of fine and gross motor praxis.  Findings:  The physician reviewer found that the occupational therapist also noted difficulties in sensory modulation and recommended remedial therapy. Sensory integration therapy was introduced by Ayres many years ago, on the assumption that behaviors could be modified by alteration of the established sensory developmental patterns that were in place. Lane and Schaaf explore the evolution of the scientific supporting evidence that behaviors can be modified by sensory input. Miller and colleagues support the efficacy of sensory modulation. Additionally, partial acceptance of sensory modulation is expressed in the report of the American Academy of Pediatrics, which states that there is no universal accepted framework for diagnosis of sensory integrative disorders (Zimmer, et al.). In sum, there is adequate evidence of the efficacy of sensory modulation techniques to support its use in this setting. Based upon the documentation provided, the patient has a significant motor problem and requires therapy in an attempt to improve his fine motor performance. All told, it is medically necessary that the patient receive the requested occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested the use of a continuous passive motion machine for the treatment of the enrollee, who is status post knee surgery. Findings:  The physician reviewer found that this patient is status post arthroscopic anterior cruciate ligament reconstruction, partial medial and lateral meniscectomies and removal of loose bodies. Use of the continuous passive motion machine was clinically indicated for this patient. Per Canale and Beaty, use of both active and passive motion modalities is indicated for patients who are status post cruciate ligament repair.  It is common practice to utilize a continuous passive motion machine in this clinical situation to aid in post-operative rehabilitation. Medicare guidelines allow reimbursement for continuous passive motion devices following cruciate ligament repair or total knee replacement when use of the device is commenced with two days following surgery and coverage is limited to a three-week period following surgery. All told, there is adequate evidence to support this patients use of a continuous passive motion device during the period at issue.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for speech therapy for treatment of his speech disorder. Findings:  The physician reviewer found that the origin of the speech dysfunction is congenital, and its etiology is related to a brain neurodevelopmental dysfunction. The speech therapy as prescribed is the standard of care for the patients condition, and there is no documentation that suggests the patient will not benefit from treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with a history of psoriasis. He has significant disease with involvement of over 30% of his body. His provider is requesting approval of the anti-TNF drug, Enbrel (entanercept). He has had suboptimal response to treatment with Soriatane and phototherapy. The submitted records include two years of clinical notes from his dermatologist. There are also laboratory records provided from February 2005 that note a normal CD4 count and an HIV DNA of 956/ml.  In the same battery of tests, there are abnormal liver function tests: the ALT is 88 (normal 1-40 U/L) and the AST is also elevated. It is unclear based on the records provided whether there is an explanation for these values. However, they are consistent with chronic viral hepatitis. The Health Plan has denied authorization for Enbrel based upon their determination that it is not medically necessary absent a negative tuberculin screening.Use of anti-TNF therapy in patients at risk for infection is of serious theoretical concern. A recent paper in Medicine noted the occurrence of cryptococcal, pneumococcal and mycobacterial infections in patients receiving entanercept and related agents. Similarly, a study published in Mayo Clinic Proceedings in 2000 noted multiple infections in a patient given this therapy. A post-marketing study of Enbrel identified serious infections associated with its use and led to a revised prescribing recommendation in May 1999.Based on this data, tuberculosis must be ruled out in the presence of HIV disease (and possibly chronic hepatitis). Anti-TNF drugs such as Enbrel need to be used with extreme caution.  If these criteria are met and the patients CD4 count and HIV viral load are near normal/negative, Enbrel could then be considered as a possible therapy with very careful monitoring.For the reasons set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.