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

Nature of Statutory Criteria/Case Summary: The patient is a female who requested authorization and coverage of Orencia ClickJect autoinjector. The Health Plan has denied the request for authorization and coverage of the medication Orencia ClickJect, indicating that Enbrel and Xeljanz or Xeljanz XR should be trialed before Orencia ClickJect. The U.S. Food & Drug Administration (the FDA) has approved abatacept (Orencia) for the treatment of patients with moderately to severely active RA who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors (TNFi). (package insert; and Med Lett Drugs Ther).  Two Cochrane system reviews from 2009 and 2010 indicate that abatacept appears to be safe and efficacious. This medication appears to be most effective in certain subsets of RA patients. One subset includes patients with active RA who are resistant to either methotrexate (MTX) or the combination of MTX and anti-TNF agents. Another subset includes MTX-naive patients with early RA and poor prognostic indicators. These factors include patients who were methotrexate-naive and seropositive for rheumatoid factor, anti-cyclic citrullinated protein type 2, or both, and who had radiographic evidence of joint erosions.  In this case, the patient has a history of seronegative RA, positive ANA, Lyme disease, and GI issues. Given the patients GI issues, Xeljanz would not be recommended. The patient has failed treatment with two TNFi medications, Simponi and Humira. Given her Lyme disease, a TNFi would not be a preferred agent and Enbrel would not be recommended. The medical literature does not discuss the use of anti-TNF agents in patients with autoantibodies associated with lupus. The package insert recommends against the use of anti-TNF agents in patients with these autoantibodies. Orencia ClickJect does not have this concern or warning. Under these circumstances, Orencia ClickJect is medically necessary to treat the patients medical condition.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 allergy and immunology, and internal medicine, with subspecialty certification in rheumatology 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 28-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of his bipolar 1 disorder, mixed phase, severe, with psychotic features, attention deficit/hyperactivity disorder, combined type, panic disorder with agoraphobia, hypochondriasis, methamphetamine dependence, alcohol abuse and non-compliance with psychiatric treatment.  Findings:  The physician reviewer found that a psychologist attempted to complete psychological testing, but the patient was too disorganized for testing and the medical records documented paranoid ideation. The patients judgment was impaired.  In this patients case, inpatient psychiatric hospitalization from the date in question forward was and is medically indicated. The patient requires intense treatment in a 24-hour setting with close monitoring until he is stable.  He is not a candidate for treatment at a lower level of care given the acuity and severity of his illness. All told, inpatient psychiatric hospitalization during this period forward was and is consistent with American Psychiatric Association practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old woman who underwent a needle localization breast biopsy in May 2003 that resulted in a scar on her left breast. The patient consulted a plastic surgeon in December 2003 while the incision was very immature. The plastic surgeon recommended that the patient undergo scar revision. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is not medically necessary.The submitted records lack documentation of the medical necessity for the proposed scar revision. The documentation provided includes a surgical consultation regarding an immature scar of the left breast. The submitted photographic evidence demonstrates an immature scar. Based upon the information that has been provided, there is no indication of a physical need for scar revision at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee, with diagnoses of autism and seizure disorder, has requested authorization for occupational therapy (OT). Findings:  The physician reviewer found that there is insufficient evidence to support sensory integration (SI) OT as a treatment for autism and no convincing outcomes data showing a long-term benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for Nutropin AQ Nuspin. Findings: Based on the available documentation, this patient meets the standard of care criteria for growth hormone therapy based on two failed growth hormone standard provocative tests, prior growth velocity below the 10th percentile for age and gender tracked over at least one year, delayed bone age, and appropriate GH dosing. Although the patients height is just above the third percentile, their growth pattern persists below the 10th percentile which may fall below the familial pattern. A six-month trial of growth hormone therapy is warranted to assess the patients clinical response. All told, Nutropin AQ Nuspin was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 20 days of partial hospitalization program (PHP). The submitted documentation fails to demonstrate the medical necessity of the requested services. The progress notes do not document active suicidal or homicidal ideation. There is no indication that the patient was experiencing psychosis. The patient was noted to be cooperative with treatment. The progress notes do not indicate that the patient was engaging in self-harm or aggression. The literature indicates that therapy on a consistent basis along with medication treatment is the most successful for eating disorder treatment overall. Due to the fact that the patient was overall cooperative in treatment and not experiencing severe psychiatric symptoms, regular outpatient therapy would be effective, safe and appropriate. The patient is also noted to have a diagnosis of borderline personality disorder. The records do not indicate that the patient had current significant symptoms of her borderline personality disorder, such as self-harm or severe affective lability. Per the records, the patient could be safely and effectively treated in a less restrictive setting. Thus, 20 days of PHP is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested Synvisc injections, or in the alternative, Orthovisc injections for treatment of her ankle arthritis.  Findings:  Three physician reviewers found that hyaluronic acid injections are not recommended for ankle osteoarthritis because the effectiveness for this joint has not been established by double-blinded, controlled randomized clinical trials. A review of the literature reveals preliminary studies with small numbers of patients evaluating the efficacy of viscosupplementation for the ankle. In a recent randomized controlled trial, there was no reported clinical difference in hyaluronic acid compared with single intra-articular injection of saline solution for treatment of osteoarthritis of the ankle. Given the lack of scientific data demonstrating the superiority of hyaluronic acid over placebo, the requested Synvisc or Orthovisc injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for inpatient psychiatric treatment program services and prospective authorization and coverage for future inpatient psychiatric treatment program services. This patient was admitted to the inpatient unit due to an episode of apparent psychosis. The psychiatric progress notes do not indicate suicidal ideation, homicidal ideation or adverse effects from medications. Findings:  The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. The patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, inpatient psychiatric treatment program services and future inpatient psychiatric treatment program services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: A 46-year-old male enrollee has requested authorization and coverage for Medtronic 670G insulin pump for treatment of the enrollees type I diabetes mellitus. Findings:  The physician reviewer found that Multiple studies have referenced meta analyses on insulin pumps which have been able to demonstrate improved mean blood glucose concentration, glucose variability, HbA1c (glycated hemoglobin) and to reduce insulin requirements by 14% over multiple daily injections of insulin in patients capable and motivated to use the insulin pump. It remains the best available option for type 1 diabetes. Continuous glucose monitoring systems (CGMS) including real time systems have been approved by the U.S. Food and Drug Administration. This patient may see a benefit in personal CGMS device. However, the Medtronic 670G insulin pump is a hybrid closed loop pump. This device is partially automated, a hybrid system (not fully automated), in that only the basal insulin doses are automatically adjusted depending on CGM results. Patients need to manually request prandial insulin doses. Although the preliminary results are promising from a smaller study, additional large scale long term trials are needed to be performed in the future for the Medtronic 670G hybrid. Therefore, the requested device is considered investigational as long term studies on this new system are not yet available. As such, Medtronic 670G insulin pump is not likely to be superior to the available standard options for the treatment of this patients medical condition.  Final Result: All three reviewers determined that the requested device is 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 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.Physician reviewer number two is board certified in internal medicine with sub-specialty 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.Physician reviewer number three is board certified in internal medicine with sub-specialty 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: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested for inpatient substance abuse rehabilitation for treatment of his alcohol dependence. Findings:  The physician reviewer found that there is no reported history of a psychiatric diagnosis other than alcohol-related. In cases such as this, it is appropriate to utilize an evidence-based, objective instrument such as the Level of Care Utilization System (LOCUS) to determine the necessary level of care to insure the level of care meets individual needs safely and effectively, in the least restrictive setting possible.  Application of these guidelines yields the following scores: 1) Risk of harm - moderate, 2) Functional status - moderate, 3) Medical, Addictive and Psychiatric Co-Morbidity - minor, 4A) Recovery environment -moderate, 4B) Recovery environment, level of support - supportive, 5) Treatment and Recovery history - moderate, 6) Engagement and Recovery Status - limited.  This gives a composite score of 19.  A score of 19 correlates with a treatment intensity level of three which is high intensity community based services. Thus, based on LOCUS guidelines, the patient could have been appropriately treated at a less intensive level of care. The submitted evidence also does not establish that the patient met American Psychiatric Association guidelines for inpatient substance abuse rehabilitation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with cranial/head somatic dysfunction, cervical somatic dysfunction, thoracic somatic dysfunction, rib somatic dysfunction, lumbar somatic dysfunction, sacral somatic dysfunction, pelvic somatic dysfunction, upper and lower extremity somatic dysfunction, abdominal somatic dysfunction, low back pain, neck pain, and foot pronation. The patient reported left shoulder pain. Physical examination findings included decreased range of motion in cervical spine flexion, side bending, and rotation. Thoracic spine range of motion was decreased in side bending and rotation. Scapular dyskinesia was noted with restrictions in the left pectoralis minor, left clavicle, and left biceps tendon. The therapy recommended by the provider included ligamentous balancing, diaphragm release, lumbosacral decompression, condylar decompression and cranial osteopathy. The patient has requested coverage for osteopathic manipulative therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether osteopathic manipulative therapy is medically necessary for the treatment of the patients medical condition. Manual therapy consists of manipulation and mobilization and can include many techniques. Mobilization involves assisted, low-force, low-velocity movement and manipulation involves a higher-force, higher-velocity with low amplitude action moving a target joint. Manipulation or mobilization of the lumbar, cervical and/or thoracic spine is recommended for short-term relief of pain or as a component of an active treatment program. Although support can be found for the use of thoracic manipulation for neck pain, function, and quality of life, results for cervical manipulation and mobilization are few and diverse. Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function, with transient minor musculoskeletal harms. Although manipulative therapy can be utilized for the treatment of acute back and neck pain, the record does not support that this was how the osteopathic manipulative therapy will be used for this patient. There is a lack of evidence on the clinical efficacy of cranial osteopathic manipulative medicine. Medical evidence does not support the requested services in this clinical setting. Therefore, osteopathic manipulative therapy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 59-year-old male has requested Voltaren 1% gel topical (100) for the treatment of his right pes bursitis and osteoarthritis. Findings:  The physician reviewer found that the request for Voltaren 1% gel topical stems from the patients desire to avoid having to take additional oral medications. The records from the patients physician do not document a swallowing defect. Nor is there data to substantiate the contention that the use of topical medication will negate the risks posed by oral NSAIDs. Per the Manufacturers Prescribing Information, use of Voltaren 1% gel can increase the risk of hyperkalemia, especially in patients with diabetes mellitus. The associated risks are similar to those of oral NSAIDS. Given the absence of evidence of an intrinsic swallowing defect, the necessity of Voltaren 1% gel has not been established.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for surgery to straighten the right hallux (big toe). The smoking of cigarettes can slow down and/or reduce the ability of bones to heal after surgery. Procedures involving arthrodesis, fracture open reduction internal fixation, and plastic surgery have been associated with negative outcomes in smokers. Researchers noted that the osteotomy of a smoker took 1.73 times longer to reach radiographic bone consolidation than that of a nonsmoker. The patient has pain below the second metatarsophalangeal joint. Further documentation and x-ray evaluation has revealed a dorsal contracture at the second metatarsophalangeal joint with elevation of the second digit. In this patients case, records reflect that the patients bunion must be corrected in order to allow for the lowering of the second digit and alleviation of pain below the second metatarsophalangeal joint. While the patient is a known smoker, the requested surgery to correct the patients painful foot is medically reasonable and necessary. Therefore, the requested surgery to straighten the right hallux (big toe) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the name brand medication Linzess for treatment of her medical condition. The physician reviewer found that review of the submitted additional documentation fails to demonstrate the medical necessity of the requested medication. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated for treatment of irritable bowel syndrome with constipation and chronic idiopathic constipation. The additional records submitted, which includes endoscopic and radiologic imaging, provides insufficient evidence that the patient has irritable bowel syndrome or has a diagnosis of constipation, such as infrequent bowel movements, difficulty during defecation or the sensation of incomplete bowel evacuation. Therefore, the request for name brand medication Linzess is not supported as medically necessary. 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 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.