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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Uceris 9 mg extended release tablets for treatment of the enrollees microscopic colitis. Findings:  The physician reviewer found that the request for Uceris 9 mg extended release tablets is medically necessary for treatment of the patients medical condition. Microscopic colitis consists of chronic or intermittent watery diarrhea, accompanied by abdominal pain, weight loss, incontinence and arthralgias. No alterations in the large bowel are visibly appreciated by endoscopic and radiologic evaluation, so definitive diagnosis is made by histological analysis. There are two subtypes: collagenous colitis and lymphocytic colitis. No differences are appreciated in clinical presentation and management, but collagenous colitis is distinguished by a thickening of the subepithelial collagen layer that is absent in lymphocytic colitis. There is sufficient medical literature supporting the use of Uceris for the treatment of collagenous colitis. According to researchers, Recent evidence has added new pharmacological options for the treatment of microscopic colitis: the role of steroidal therapy, especially oral budesonide, has gained relevance, as well as immunosuppressive agents such as azathioprine and 6-mercaptopurine. Munch and colleagues performed a prospective, randomised, placebo-controlled study in patients with histologically confirmed active collagenous colitis who received budesonide. The authors concluded that Budesonide at a mean dose of 4.5 mg/day maintained clinical remission for at least 1 year in the majority of patients with collagenous colitis and preserved health-related quality of life without safety concerns. Uceris appropriately targets the delivery of budesonide to the colon, and has shown efficacy and tolerance in 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested group social skills therapy for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is evidence that social skills groups are effective for children with autism spectrum disorders (ASD) to improve social skills and friendship quality. However, most of the peer-reviewed literature in regards to social skills groups does not include children who are also receiving applied behavior analysis (ABA). Social skills groups are designed to refine communication and work on conversational reciprocity and staying on conversational target. In this case, the patient has good communication skills, but limitations in his reciprocity with conversation. This is likely a social skills group goal that should be addressed in a group social skills therapy. In this clinical setting, a social skills group therapy in addition to ABA services is indicated for this patient.  For the reasons stated, group social skills therapy is medically necessary in this clinical setting.   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 pediatrics with sub-specialty certification in developmental and behavioral 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

A 64-year-old female enrollee has requested for continued weekly psychotherapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with affective disorders, such as major depressive disorder.  Current practice in this country is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  As noted by the American Psychiatric Association, factors to consider when determining the frequency of psychotherapy for individual patients include the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns.  The American Psychiatric Association guidelines note that if four to eight weeks of treatment do not yield at least moderate improvement, the treatment plan should be thoroughly reviewed and reappraised by the provider.  The submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  It is not uncommon for patients to receive weekly psychotherapy sessions in times of crisis or excessive symptom burden, and this is consistent with good medical practice.  However, the records do not support the requested frequency of treatment in this patients case.  All told, continued weekly psychotherapy is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for omeprazole sodium bicarbonate 40 mg-1.1 gram for treatment of the patients gastroesophageal reflux disease (GERD) with esophagitis.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD) with esophagitis. The submitted documentation supports the medical necessity of the requested medication. The American College of Gastroenterology guidelines recommend proton pump inhibitor therapy for enrollees with GERD and esophagitis. This enrollee has failed prior treatment with multiple formulary proton pump inhibitors. It is unlikely that re-trial of these medications would be effective. Continued proton pump inhibitor therapy is supported by the current guidelines. The records indicate that this enrollee had improvement with omeprazole sodium bicarbonate. Therefore, omeprazole sodium bicarbonate 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 enrollees 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for finasteride 1 mg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Finasteride 1 mg is approved by U.S. Food and Drug Administration for treatment of male pattern baldness. The current medical literature does not support the efficacy of finasteride 1 mg in the management of patients with benign prostatic hyperplasia. In addition, the submitted medical documentation does not support the diagnosis of benign prostatic hyperplasia, as symptoms related to benign prostatic hyperplasia are not documented. All told, finasteride 1 mg is 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 urology 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 13-year-old female with a history of reflex sympathetic dystrophy to her left knee after a fall in March 2004. The patient has experienced progression of symptoms including increasing pain in the left leg with changes in skin temperature and color changes to the skin. She was diagnosed with reflex sympathetic dystrophy. The patient has been followed by a pediatric neurologist and a physical therapist. She also underwent a single course of steroid injection. The patient then underwent a trial of Dynatron sympathetic therapy, with reported benefit. A request has been made for continuation of Dynatron sympathetic therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients medical condition. Review of the literature regarding all forms of functional electric stimulation as treatment for reflex sympathetic dystrophy reveals there are no placebo-controlled or even randomized studies supporting the therapy. Additionally, the description of the mechanism of the treatment has not been evaluated. The electrical stimulation required to reach the spinal cord reflex arc is significantly more than the stimulation provided in functional or therapeutic electrical stimulation. Yet, the technology reportedly uses lower stimulation thresholds than other electrical stimulants, which are more tolerable. This does not appear to be logical from a physiological standpoint.Though standard therapeutic electrical stimulation has been shown to relieve pain in patients with chronic pain, over time the frequency and duration of the stimulus need to be increased and eventually it becomes ineffective. Given no objective evaluation of the involved technology and the lack of physiological basis, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for coronary CT scan for evaluation of coronary artery disease for evaluation of his cardiac risk. Findings:  Three physician reviewers found that the submitted clinical evidence demonstrates that this patient is not obese, is not hypertensive and he jogs 30 to 45 minutes per day with no symptoms. He has a low Framingham risk profile. Per the current medical literature, coronary CT scan is not indicated in this clinical scenario. The patient did not meet clinical indications for coronary CT scan based on the American College of Cardiology/American Heart Association guidelines.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for percutaneous coronary intervention (coronary revascularization). The 2017 Appropriate Use Criteria for Coronary Revascularization indicate that in patients with significant left main disease along with other involved coronary vessels, coronary artery bypass surgery is the preferred intervention. Furthermore, in the setting of 1, 2, or 3 vessel disease along with left anterior descending involvement, percutaneous coronary intervention (PCI) is less preferred, being associated with higher re-stenosis rates and re-intervention requirements including coronary artery bypass grafting (CABG). In this case, the submitted records show that the patient had severe left main disease also involving the ostium of the left anterior descending and left circumflex coronary arteries. In this circumstance, revascularization is preferred, especially with severe ischemia identified on stress testing. Given patient preference, however, PCI is a reasonable, though less effective, alternative. Therefore, percutaneous coronary intervention (coronary revascularization) was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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 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

A 56-year-old male enrollee has requested a bone marrow transplant at the Mayo Clinic using the Bone Transplant Protocol for the treatment of his multiple myeloma. Findings:  The physician reviewer found that this patient was initially referred to Stanford University. However, he wishes to get the transplant at Mayo Clinic since they use a melphalan-based transplantation which avoids cardiotoxicity, and he considers it to be safer. The patient is under the impression that the Stanford protocol uses high-dose Adriamycin. The bone marrow protocol from Stanford University which has been attached uses cyclophosphamide/etoposide as induction regimen for stem cell collection followed by BCNU/melphalan as high-dose therapy prior to the transplant. This regimen from Stanford is considered a standard regimen for the autologous stem cell transplantation. I do not see evidence of the use of Adriamycin in this treatment plan as contended by the patient. The Mayo Clinic protocol has not been submitted. In view of this, the Health Plans decision should be upheld because the autologous stem cell transplantation at a center of excellence (Stanford University) is not inferior to the standard of care. There is no medical necessity for the patient to receive treatment at the Mayo Clinic.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested a pain management consultation for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested pain management consultation in this patients case.  There is lack of documentation regarding the patients response to conservative therapy.  Conservative therapy includes physical therapy and non-steroidal anti-inflammatory medications.  Niemisto and colleagues performed a prospective randomized controlled trial to examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain.  The authors concluded that the manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone. The study showed that specific treatment programs with proper patient information may alter the course of chronic low back pain.  All told, the requested service is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Concerta and modafinil for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that Concerta is a methylphenidate-based product that was approved by the U.S. Food and Drug Administration (FDA) for the treatment of attention deficit hyperactivity disorder (ADHD) in 2000. Concerta is a central nervous system psychostimulant that is thought to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. Modafinil is not a stimulant, but rather a novel wake-promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus. Modafinil is approved by the FDA for excessive sleepiness associated with narcolepsy, obstructive sleep apnea, and shift-work sleep disorder. Although modafinil has demonstrated promising results in the treatment of ADHD, the FDA has not approved the agent for this indication in the absence of rigorous scientific trials demonstrating the long-term safety and efficacy of the medication. This patient does not have narcolepsy, obstructive sleep apnea, or shift-work sleep disorder. The medical record also noted that the patient did not meet the diagnostic criteria for ADHD. Although psychostimulants have shown promise as an adjunctive treatment for refractory depression, Concerta and modafinil are not considered evidence-based monotherapies for major depressive disorder or chronic fatigue for that matter. Thus, based on the documentation provided, the requested Concerta and modafinil are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested 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 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

The patient is a 58-year-old woman who sustained a severe fracture to her foot requiring open reduction internal fixation. Postoperatively, the patient utilized a continuous passive motion (CPM) machine for approximately two months. She has had an excellent recovery. The Health Plan approved a CPM machine for 21 days of use. According to the Health Plan, use of the equipment beyond the authorized period was not medically necessary for the patient.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM therapy. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the machine was felt to be of benefit following surgical treatment of the patients severe foot fracture. Use of the CPM machine was medically indicated beyond the 21 days authorized by the Health Plan. After using the CPM machine for 53 days, the patient regained mobility and stamina, required very little physical therapy, and was able to return to her normal routine. The patients use of the CPM machine for the period of time at issue was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the monitored anesthesia care (MAC) services. The patient had an ASA preoperative physical status classification score of 2. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research, given the patients low preoperative physical status classification score. Heuss and colleagues concluded that With careful monitoring, propofol sedation during [gastrointestinal] GI endoscopies is safe, even for high-risk patients. Thus, the MAC services provided were not medically necessary for evaluation 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 anesthesiology 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 has requested authorization and coverage for oxycodone. The Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain state that if benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In addition, the CDC guidelines noted that providers should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. Moreover, the CDC states that reasons for discontinuing opioid therapy includefailure to comply with the treatment agreement. In this case, the patient is taking high dose opioid therapy along with concurrent benzodiazepines to manage her coexisting chronic pain and PTSD. The medical records do not document that the patients chronic opioid therapy has led to significant functional improvements. Moreover, the patient has returned drug screens inconsistent with her prescribed medications. All told, the requested oxycodone is not 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 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.