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

The parent of a 16-year-old male enrollee has requested coverage for residential treatment center (RTC) services for treatment of the enrollees mood disorder not otherwise specified (NOS), bipolar disorder mixed, cannabis abuse and attention deficit hyperactivity disorder (ADHD)-inattentive type.  Findings:  The physician reviewer found that the initial criteria are still met and likelihood of benefit and return to outpatient (OP) treatment is shown by adherence to the treatment plan. The treatment notes indicate that the patient is still struggling with his mood disorder and that the family conflicts are still present, but in active treatment. Additionally, the patient is still struggling with substance abuse issues that continue to require him to avoid being around his previous peers and social environments. Further, there is more than ample documentation from the patients treatment providers who have a long history with this patient. Each of these providers explains that this patient has a persistent pattern of sudden improvement with quick relapse, time and time again. They have indicated that they are unable to provide appropriate treatment for him and all agree that he needs long-term care in a residential facility where he can stabilize and improve over an extended period of time.  In sum, the patient is likely to quickly relapse if discharged to a lower level of care at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous (IV) Rocephin therapy: 2 g/day, four days on and three days off, for three months. Findings:  The physician reviewer found that The records provided for review indicate that this patient was diagnosed with Lyme disease. However, the laboratory testing criteria used for the diagnosis is not considered within the current standard of care from the Centers for Disease Control and Prevention (CDC). Further, the specific indication for Rocephin is neurolyme, which requires evidence of a central nervous system infection. In this case, there is no documentation of a lumbar puncture or other modality confirming the presence of a central nervous system infection. Moreover, the recommended treatment for Lyme disease is doxycycline, which is one of this patients prior medical therapies. All told, IV Rocephin therapy: 2 g/day, four days on and three days off, for three months, 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 internal medicine with subspecialty 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fiasp (insulin aspart injection) 100 U/mL. The records provided for review indicate that this patient has a history of type 1 diabetes that has been managed with insulin therapy. Treatment with Novolog and Humalog was not reportedly as effective as treatment with Fiasp. The patients provider has recommended treatment with Fiasp. Continuous subcutaneous insulin infusion or insulin pump therapy is an advanced method of insulin administration that has the potential to improve glycemic control compared with multiple daily injection regimens. Glycemic control might be further enhanced by combining pump therapy with an insulin that has pharmacokinetic and pharmacodynamic profiles that more closely match physiological insulin secretion and reduce postprandial glucose excursions without increasing hypoglycemia risk (Warren, et al.). Fiasp is a fact acting insulin aspart that was designed to mimic the physiologic prandial insulin release more closely than the currently available rapid-acting insulin products (Paquot and Scheen). Recent data suggests that the use of Fiasp may reduce hypoglycemia in an insulin pump system without compromising glucose control when compared with standard insulin aspart in patients with type 1 diabetes (Boughton, et al.). Given this support, the requested Fiasp (insulin aspart injection) 100 U/mL 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 endocrinology, diabetes, and metabolism 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 doppler-guided transanal hemorrhoidal dearterialization. The Health Plan has denied this request as investigational for treatment of the enrollees condition. Findings: A multicenter randomized trial of 393 patients with grade II or III internal hemorrhoids comparing hemorrhoidal artery ligation and stapled hemorrhoidectomy found that hemorrhoidal artery ligation resulted in less postoperative pain and a shorter sick leave but was more expensive, took longer to perform, left more residual grade III disease, and required more reoperations. Otherwise, hemorrhoidal artery ligation and stapled hemorrhoidectomy had comparable complication (24 versus 26 percent) and patient satisfaction rates (>90 percent in both groups). When compared to other non-excisional procedures for hemorrhoids, such as stapled hemorrhoidopexy (PPH), dearterialization may have the added advantage of reducing the incidence of serious complications. However, despite these advantages, long-term results may be associated with higher recurrence rates compared to conventional hemorrhoidectomy. Final Result: Two of the three reviewers determined that the services at issue were 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/QualificationsAll three reviewers are board certified in gastroenterology 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

A 23-year-old male enrollee has requested residential treatment center services for treatment of his polysubstance dependence.  Findings:  The physician reviewer found that based on the records provided for review, residential treatment center services were medically necessary for treatment of this patients medical condition from the time frame specified. Modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience and mental wellness. The American Psychiatric Association (APA) supports residential treatment 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. Based on this guidance, residential placement was initially reasonable for this patient as his life was dominated by substance use. The patient expressed motivation for sobriety and the need for trauma therapy was also identified. He was described as contemplative and in the preparation stage of change during his first week of treatment. However, the patient did not attend his nutritional assessment, and failed to participate in group therapy sessions. The patient did not take his medication as prescribed and elected to skip groups. Consistent with the APA recommendations, the residential treatment services were medically necessary from the time frame specified, but are not supported as medically necessary during the subsequent time frame.
Appeal type: Medical Necessity
Decision: Overturned

 A 53-year-old male enrollee requested magnetic resonance imaging (MRI) of the ankle for medical evaluation of his left foot and ankle pain.  Findings:  The physician reviewer found that the submitted documentation supports the requested diagnostic procedure in this patients case.  Per Burge and colleagues, MRI is an optimal modality for imaging evaluation of suspected foot injury.  Cheung and Rosenberg noted that MRI is beneficial in evaluating persistent ankle pain.  In this patients case, the medical records document negative x-rays and continued pain.  Thus, MRI of the ankle may be beneficial in evaluating the soft tissue structures.  Chronic ligamentous injuries can be demonstrated on MRI.  All told, the requested MRI of the ankle is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for MRI of the left shoulder. The American College of Radiology (ACR) appropriateness criteria for the evaluation of traumatic shoulder pain notes that imaging assessment begins with conventional radiography and, depending on physical examination findings, requires MRI or magnetic resonance (MR) arthography for further assessment. In this case, the provider reported the patients clinical symptoms and examination were classic for labral tear. Conventional MRI has been shown to be up to 100% sensitive and 95% specific in the diagnosis of labral tears. Therefore, MRI of the left shoulder is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for Monovisc injections in both knees every six months.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 patient has a history of three months of relief from viscosupplementation in the past. Furthermore, the patients options are limited. The alternative is bilateral total knee arthroplasties for mild osteoarthritis of both knees. Therefore, Monovisc injections in both knees every six months were and are medically necessary for treatment of the patients medical condition.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 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: Overturned

A 54-year-old female enrollee requested scar revision of the left abdomen and fat transfer into the left abdomen for medical treatment of her late effect of surgery, painful lesion and scar condition.  Findings:  The physician reviewer found that the patient has complications related to performance of a medically necessary procedure. This is producing a functional deficit that has failed conservative management. Thus, reasonable treatments aimed at correcting complications related to a medically necessary procedure should be considered medically necessary as well.  The patient has failed conservative management and has an abnormal appearance.  This is not cosmetic surgery, as cosmetic surgery is aimed at improvement of normal structures, not abnormal ones. In sum, the patient has complications related to a medically necessary procedure and she has failed typical conservative management. Therefore, the planned surgical treatment is consistent with reconstructive surgery and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-five year-old female who has been diagnosed as having post traumatic stress syndrome and attention-deficit hyperactivity disorder (ADHD) is requesting reimbursement and prospective authorization of Provigil.  Reviewers Findings:  The reviewing physician found that Provigil is still considered investigational for the treatment of ADHD and depression as there are concerns about its safety and side effects including rash, liver toxicity and cardiovascular symptoms.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for a loop recorder (implantable ambulatory event monitor). Although this patient has a remote history of lone atrial fibrillation secondary to alcohol intake, he has no high-risk symptoms such as syncope, and there is no report of a stroke or transient ischemic attack. The patients symptoms of transient dizziness and premature ventricular contractions (PVCs) occurred in the setting of normal left ventricle function. The patient underwent placement of a loop recorder for evaluation of his symptoms. There is adequate data to support an indication for implantable loop recorder devices in the evaluation of patients with cryptogenic stroke, post atrial fibrillation ablation to monitor effectiveness, or for patients with persistent and repeated palpitations, syncope, or near syncope when external monitoring has been unrevealing. In this instance, the patient presented with transient symptoms of dizziness with no atrial fibrillation when evaluated in the emergency department, with a remote history of lone atrial fibrillation associated with alcohol intake many years prior. Given the patients minimal symptoms and lack of high-risk features, external monitoring with an auto-triggered or patient-activated event recorder, or a patch-type monitor, was appropriate for initial evaluation. In this clinical situation, an implantable loop recorder as an initial evaluation was not medically necessary prior to external monitor evaluation. Therefore, the loop recorder (implantable ambulatory event monitor) was not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested substance abuse rehabilitation residential treatment services for treatment of his substance abuse treatment.  Findings:  The physician reviewer found that the substance abuse rehabilitation residential treatment services were not medically necessary for treatment of the patients medical condition. On admission to residential treatment the patient was not in withdrawals nor was he at risk for the development of withdrawals. His psychiatric comorbidity was not of a severity that required 24-hour supervision in a restricted setting. Medically he was stable. There was no homicidal ideation, plan, or intent, and he did not represent a danger to others. Although his psychosocial assessment indicated suicidal ideation without plan or intent, ongoing passive suicidal ideation is a hallmark feature of many psychiatric illnesses. In and of itself it does not constitute a rationale to admit a patient to a residential setting without the presence of concomitant aggressive behavior, intent, planning, substance abuse and withdrawal. In regards to the incident where the patient drank rubbing alcohol and blacked out, the patient specifically indicated that this was for purposes of becoming intoxicated and was not suicidal in nature. His cognitive and thought processes were intact and there was no risk of impairment in the patients self-care capabilities. He required structure to work on issues such as coping mechanisms, relapse triggers, and accepting consequences for his actions, however this could have been accomplished at a lower level of care. His family was supportive of his treatment and recovery and he had been seeing a psychotherapist weekly since 2012. In sum, the patient did not meet American Society of Addiction Medicine criteria for residential level of care. He did not require 24-hour monitoring and he could have received treatment at a lower level of care with augmentation by supportive and structured community based resources such as Alcoholics Anonymous. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested Dexilant 60 mg for medical treatment of her chronic gastritis and reflux associated esophagitis with history of helicobacter pylori (H. pylori).  Findings:  The physician reviewer found that in this case, the patient has a documented attempt at modified diet, and documented failure on multiple typical PPIs with need for over-the-counter therapy and significant abdominal pain interfering with sleep. She also has demonstrated success on Dexilant for two years, with recurrence of considerable symptoms after reverting back to typical proton pump inhibitors. In this case, Dexilant is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of her oligodendroglioma.  Findings:  Two physician reviewers found that FoundationOne gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. However, the medical evidence has not established that FoundationOne gene testing was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is 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 Sovaldi and Daklinza for treatment of his medical condition.  Findings:  The physician reviewer found that a according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, patients with cirrhosis are high priority for therapy. The guidelines recommend that cirrhotic interferon-ineligible patients with genotype 2 hepatitis C who have failed Sovaldi and ribavirin regimens should be treated with Sovaldi and Daklinza and ribavirin for 24 weeks. This is based partially on the results of two clinical trials (Sulkowski, et al; Wyles, et al). Sovaldi and peg-interferon with ribavirin is also recommended, but this patient is interferon-ineligible due to thrombocytopenia, and also has depression and anxiety which can be worsened by ribavirin (Dusheiko, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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.