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

Nature of Statutory Criteria/Case Summary: An enrollee has Ampyra for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This medication was tested with a timed walk, as it is a relatively easy end-point to measure.  The Health Plan is using a 20% improvement from baseline as the requirement for coverage for Ampyra and does not take into account multiple sclerosis relapse or natural progression of disease that may cause worsening of gait.  This patient appears to have had significant worsening in her overall disability including walking ability, and a slowing of 25-foot timed walk would not necessarily indicate a failure of the drug, but a worsening in underlying multiple sclerosis.  If this patient initially responded well to Ampyra, it is likely the drug will continue to have a positive effect.  All told, the requested Ampyra is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old woman with osteopenia of the spine without vertebral or other fractures. The patient has declined hormone replacement therapy. She has requested authorization for Miacalcin nasal spray. The patients request has been denied by the Health Plan on the basis that the requested medication is not medically necessary in the absence of a diagnosis of osteoporosis.Upon review of the submitted information there is no evidence that Miacalcin nasal spray is medically necessary. There is no evidence that the patient has a history of fracture; nor is there any indication of osteoporosis. Miacalcin is not indicated for prevention of osteoporosis. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male with a history of low back and right leg pain beginning in 2000. His provider noted the pain was increased by standing or walking. Imaging studies confirm a disc pathology at L4-5. Several conservative treatment approaches were attempted and apparently epidural steroid injections were effective for the patients back pain, but not the severe leg pain.  The patient consulted with a non-Plan provider who recommended endoscopic lumbar discectomy and the procedure was performed in June 2006. The patients request for reimbursement of the cost of the procedure was denied by the Health Plan citing a lack of medical necessity.Endoscopic discectomy is an investigational procedure without scientifically established clinical benefit. While some clinicians do advocate for the procedure, conclusive proof of efficacy remains elusive. This procedure is associated with significant complications and there is a high incidence of revision.  As the patients condition was amenable to more standard treatment modalities, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old woman who has had generalized psoriasis involving 75% of her body surface including her face. Treatment with topical corticosteroids Dovonex and Tazorac has been ineffective. The patient and her dermatologist have requested coverage for Enbrel because the patient is of childbearing age. The Health Plan had denied coverage for Enbrel on the basis it is not medically necessary for treatment of the patients condition. Enbrel is the only medically necessary and reasonable treatment for this patients extensive psoriasis. Methotrexate and Soriatane are category X drugs and should not be used during pregnancy. Women using Soriatane should not get pregnant for three years after cessation of the drug. Cyclosporine is a medication to be used for severe acute generalized psoriasis, not long-standing psoriasis. It must be stopped after six months because of the high incidence of kidney damage. Methotrexate has more frequent and serious side effects than Enbrel. Because Enbrel has a short half-life, it can be stopped when the patient becomes pregnant with safety for mother and child. As such, use of Enbrel is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested four hours per week of Denver Model Applied Behavioral Analysis (ABA) therapy together and concurrent with 12 hours per week of DTT Model ABA therapy, in addition to the current 8 hours per week of Denver Model ABA therapy the enrollee is currently receiving for treatment of his autism.   Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (ASD). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A five-year randomized controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. A recent retrospective study compared a group of school aged children who had been diagnosed with an ASD when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning ASD. The authors reported that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high functioning group received this level of intervention (Kelley, et al). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity (minimum 25 hours per week) in order to provide optimal outcomes (Granpeesheh, et al). Sallows and Graupner noted that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. Many studies noted improvement of function in goals for older children with ASD using intensive ABA interventions. These are often tailored to meet the individual needs of the patient. The goals for older children often are to identify and remediate particular deficits such as noncompliance, communication, social skills deficits, leisure, and daily living skills, as with this patient. This patient should continue to receive ABA therapy as recommended by the provider and is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Idiopathic short stature is among the U.S. Food and Drug Administration (FDA) approved indications for growth hormone therapy. Idiopathic short stature is defined as standing height below -2.25 SDs in the absence of identified cause. This patients records do not include adequate documentation to meet the essential diagnostic criterion for idiopathic short stature. Specifically, his bone age has not been delayed recently, although his most recent growth velocity was slightly lower than expected for a prepubertal male his age. His most recent predicted adult height is within the normal range for North American males, which is above 64 inches. The clinical history and current presentation do not support an indication for treatment with growth hormone therapy. For these reasons, the requested Nutropin AQ Nuspin is not medically necessary for this patient. Final Result: The reviewer determined 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 pediatrics with subspecialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested echocardiography and a repeat stress echocardiography for evaluation of his  coronary artery disease.  Findings:  The physician reviewer found that in the setting of rare stable angina and favorable stress test results, continued medical therapy has been demonstrated to be the preferred treatment approach (Boden, et al). Moreover, current guidelines endorsed by several national organizations do not consider annual repeat stress testing or stress testing less than two years from the prior exam appropriate in patients with stable symptoms (Douglas, et al). Consistent with these findings, the repeat stress echocardiogram planned for the date indicated is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested a Roux-en-Y gastric bypass for treatment of her obesity. Findings:  The physician reviewer found that with a BMI greater than 35 and a number of documented comorbidities, laparoscopic Roux-en-Y gastric bypass is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure. There is adequate peer-reviewed medical literature supporting the safety and efficacy of the Intracept procedure for treatment of this patients neck and back pain. Imaging revealed Modic endplate changes at L4-5 and L5-S1 and symptoms that have persisted for longer than six months. The current modalities for these patients are fusion or artificial disc replacement. Intracept offers a less invasive outpatient procedure that will maintain the structural integrity of the spine. Patients have been shown to have significant improvements in pain and overall return to high functioning levels with the Intracept procedure. For these reasons, the requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Intracept procedure 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 orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested nerve blocks (CPT codes 64505, 64405 and 20553) for treatment of her temporomandibular joint disorder. Findings:  Three physician reviewers found that the services at issue were not and are not likely to be more effective for this patient than other available options. Blumenfeld and colleagues conducted a meta-analysis of published peer reviewed literature and concluded that with the exception of cluster headache, there is a paucity of evidence supporting the performance of peripheral nerve blocks in the treatment of headache disorders. In this case, the medical records provided for review report a condition of oromandibular dystonia with associated mixed headaches, and not cluster headache. The physical examinations report occipital tenderness but do not indicate any specific occipital neuralgia, specific trigger points or indicate any signs and/or symptoms related to sympathetic mediated pain. As such based on the medical records provided for review, the nerve blocks provided from the time period specified were not likely to be more beneficial for treatment for the medical condition of oromandibular dystonia and mixed headaches than any other available standard therapy. Furthermore, future nerve blocks are not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old male who was previously diagnosed with borderline personality disorder, polysubstance abuse, and post-traumatic stress disorder with several inpatient hospitalizations for depression and suicidality (one from 8/27/04 to 9/16/04 and the most recent from 10/11/04 to 10/15/04). Inpatient stays have often been preceded by use of amphetamine as well as alcohol. The stays themselves are marked by the patients dramatics and disgruntlement. The last hospitalization ended in the patient leaving against medical advice. At that point, he was offered different options including intensive outpatient treatment, residential placement, partial hospitalization, and dialectical behavioral therapy (DBT), all of which he refused, demanding instead to leave immediately. His psychiatrist for both the first and second hospitalization noted, his axis II personality disorder has dominated his clinical course, the same as during previous hospitalizations. Elsewhere, he was noted to be very manipulative, demanding, attention-seeking, and was emotionally labile. He was also exhibiting self-defeating and self-destructive behavior by pushing away help and treatment offered to him. Finally, he was said to be inappropriate and intrusive and did not follow the instructions of the group coordinator in some of the groups so he was dismissed from a couple of the groups. At the time of his discharge against medical advice, he was not suicidal and was discharged with a regimen of Lexapro 10mg and Seroquel 25mg.The Health Plan has denied the patients request for individual weekly psychotherapy suggesting that he pursue treatment in a chemical dependency recovery program prior to undergoing psychotherapy.Review of the patients records indicates that he has only been marginally dedicated to treatment of any kind. The patients contention is that he requires out-of-plan therapy. However, there is no evidence that the Health Plan cannot or will not provide him with capable psychiatric services. The Health Plan recommends the patient successfully complete a chemical dependency recovery program prior to psychotherapy. It is within the purview of the Health Plan to decide on the optimal ordering of how services ought to be offered, particularly given the patients character pathology. It is not unreasonable, for example, for the Health Plan to mandate that the patient stop abusing amphetamines and alcohol before more meaningfully engaging in psychotherapy. As such, individual weekly psychotherapy is not medically warranted at this time.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested genetic testing (whole genome sequencing) for evaluation of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. Based on the records provided, the patient has multiple medical conditions as well as symptoms of intermittent dizziness, palpitations and hot flashes of uncertain origin. In this clinical setting whole genome sequencing is not medically necessary and not the standard of care for evaluating her medical condition. Whole genome testing may provide a generalized risk assessment for certain conditions influenced by genetic polymorphisms, however it would not be expected to provide a diagnosis for the patients symptoms and also has not been shown to improve outcome in the circumstance described. This is in contrast to genetic testing for a specific gene defect in a proband with an inheritable medical condition or in a first-degree family member at risk for inheriting a specific medical condition. In addition, there is a lack of scientific evidence in the peer-reviewed literature to support the use of whole genome testing to aid in the clinical diagnosis of symptoms as in this patients case. Based on the medical literature and the documentation submitted for review, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested residential behavioral health treatment services for treatment of the enrollees schizophrenia, paranoid type. Findings:  The physician reviewer found that the provider noted initially that the patient was psychotic, internally stimulated, agitated, and paranoid about his parent.  Subsequently, the patient did show some improvement and could have been transferred to less restrictive setting such as a residential treatment facility. Based on these facts and considering the totality of the circumstances, the residential behavioral health treatment services were initially medically necessary for treatment of this patients medical condition. A portion of the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell function assay with stimulation blood test performed for evaluation of the enrollees dilated cardiomyopathy status post heart transplant. Findings:  2/3 of the physician reviewers found that based on the records provided, the patient is status post cardiac transplantation who is documented to be clinically stable. In this setting of prior cardiac transplantation periodic monitoring for rejection is reasonable, appropriate, and considered standard accepted practice in the medical community. Standard monitoring for rejection includes periodic clinical evaluation, periodic echocardiographic evaluation, periodic endomyocardial biopsy and/or gene expression profile testing in lieu of endomyocardial biopsy in stable patients. In this circumstance, additional monitoring with immune cell function assay testing has not been shown to be of incremental clinical outcome benefit in any adequately controlled trial. Current guidelines that are endorsed by several national organizations also do not recommend routine surveillance with immune cell function assay testing to assess cell mediated immunity in post heart transplantation recipients. For the reasons provided, cell function assay with stimulation blood test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.