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

A 50-year-old male enrollee has requested for extreme lateral interbody fusion (XLIF) at the L3-4 spinal level for treatment of his degenerative disc disease. Findings:  The physician reviewer found that there is inadequate medical documentation submitted to substantiate the presence of spinal instability above the levels of this patients prior L4 to S1 fusion. Supine radiographs fail to reveal spondylolisthesis in 20% of patients. Flexion- extension views may reveal subtle or unstable slips accentuated by flexion and reduced in extension. If instability is present and is indeed documented in lateral flexion-extension views, then there would potentially be a rationale for extending this patients fusion more proximally. However, without demonstration of specific mechanical instability and with this patients multiple comorbidities, it is not medically necessary for this patient to proceed with an extreme lateral interbody fusion of the lumbar spine (XLIF) at the L3-4 level.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Sovaldi 400 mg tablets for medical treatment of the her hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) for treating patients with hepatitis C virus support the safety and efficacy of Sovaldi in this clinical setting. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. Consistent with these findings, the requested Sovaldi 400 mg tablets are medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female has requested botulinum toxin injections for treatment of muscle spasms.  Findings:  Two physician reviewers found that botulinum toxin is an accepted treatment for cervical dystonia and various types of headaches in patients who have failed standard therapies. In this instance, the patient has severe muscle spasms refractory to medications and non-pharmacological interventions. She did however respond to a trial of Myobloc. As is the case with migraines, since standard interventions were not helpful, a trial of botulinum toxin was clinically reasonable and was shown to be effective for this patient. Continued treatment with Myobloc is indicated as long as a positive response is documented.
Appeal type: Medical Necessity
Decision: Upheld

The mother of an eight-year-old female enrollee has requested Singulair for the treatment of the enrollees asthma. Findings:  The physician reviewer found that treatment with ICS (e.g., Qvar) is the preferred method of managing persistent asthma that requires daily medication to manage symptoms. Use of a leukotriene modifier (e.g., Singulair) is an appropriate addition to therapy if symptoms are inadequately controlled with ICS alone. The clinical information and medical records provided fail to demonstrate that this patient has had inadequately controlled symptoms with ICS alone. Rather, it appears from the provided information that she has not taken prescribed medications as recommended. If there is documentation indicating that she was prescribed and using ICS, but symptoms were inadequately controlled at the time of the prescription, then the request for Singulair should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female is requesting the medication Aciphex for the treatment of her acid reflux. Findings:  The physician reviewer found that PPIs continue to be the backbone of therapy for GERD and are superior to other treatments in providing excellent relief of symptoms as well as healing of erosive and non-erosive esophagitis.  For the most part, all PPIs are equally effective and equivalent in their potency and control of acid secretions.  However, patients differ in their response to specific PPIs. This differential efficacy between patients has been seen with PPIs because of differences in the individual levels of the polymorphically distributed cytochrome P450 (CYP) 2C19 enzyme. In this case, the patient has tried Protonix and Prilosec with no relief.  In addition, the patient has had allergic/adverse reactions with Prevacid and Protonix in the form of nausea, vomiting, headache and neck swelling. This is contrasted with the fact that Aciphex has provided the patient the greatest benefit.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of articulation disorder.  Findings:  The physician reviewer found that there is no documentation outlining the specific criteria necessary to classify developmental speech apraxia as a disease and there is no documentation in this case that identifies a medical condition related to the speech apraxia. As a result, the speech delays are considered developmental in nature, and there is no medical indication for speech therapy. The treatment of developmental speech apraxia would typically fall under the auspices of the school system through an Individual Education Plan (IEP).
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old female enrollee has requested referral to a podiatrist for treatment of her foot pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested service in this patients case.  The medical records document painful bunions and hammertoes.  The patient was advised to wear wider shoes.  However, she continued to have pain.  A bunion deformity is considered a misalignment of the first metatarsophalangeal joint which results in a large painful bump to the medial aspect of the joint.  This condition may inhibit normal ambulation.  Treatment of bunion deformities and the pain that they cause begins by wearing wider shoes.  If this does not alleviate the patients pain, then surgical correction is warranted.  In order for this patient to be evaluated for surgical correction of her bunion, an evaluation by a podiatrist is necessary.  All told, the requested referral to a podiatrist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Three physician reviewers found that according to the most recent 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 HCV regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation per AASLD/IDSA. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug (FDA) approved for all patients with chronic HCV genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni for 12 weeks should be considered medically necessary in this case.  Final Result:  Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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

The patient is a 64-year-old male who has extensive psoriasis affecting his scalp, trunk, arms, legs and feet. His provider has prescribed the application of Dovonex cream twice per day and by the providers assessment, 80% of the patients lesions are under control.  The patient has indicated that he needs to apply the medication three to four times per day. The patients provider has requested authorization for a three-month supply of Dovenox cream, which equals 1080 grams (three 120 gram tubes per month). The Health Plan denied the request based upon a determination that the requested medication dosage is not medically necessary.The patients provider has adequately documented the extensive nature of the psoriasis, and the need for treatment with Dovonex cream. The amount required for one months treatment is not entirely clear.  The current usage appears to be effective in treating the patients psoriasis, but the patient may be using the Dovonex three to four times per day. As prescribed, the cream should be applied twice per day.  Because the psoriasis is so extensive, it is medically necessary that the patient be provided the dosage requested by his primary care provider until he can be fully evaluated by a dermatologist.  The dermatologist can fully assess the condition of the patients skin and make a final determination as to the required dosage of Dovonex cream.Therefore, I have determined the requested medication dosage is medically necessary for treatment of the patients medical condition pending an evaluation by a dermatologist. The Health Plans denial should be overturned at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Lyrica for treatment of the enrollees thoracic outlet syndrome. Findings:  The physician reviewer found that Lyrica is supported for the treatment of seizure disorder and neuropathic pain. Lyrica is recommended for use after failure of first-line agent such as gabapentin. Current peer-reviewed medical literature has demonstrated that Lyrica is effective for treatment of patients with neuropathic pain. The medical records report this patient has a neuropathic pain condition of thoracic outlet syndrome. The records report previous treatment and failure with gabapentin. Thus, Lyrica is medically necessary based on the records provided for review.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 with sub-specialty certification in pain 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: Urgent Care
Decision: Upheld

A 20-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients Health Plan provides emergency services when medically necessary. An emergency medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the members health in serious jeopardy. This patients symptoms had commenced gradually over two days and were not acute in onset. Although she reported her pain as 9 out of 10, she was described as being in only mild distress. She attempted no intervention prior to her arrival in the emergency department, such as over the counter pain medication. Records document that the patient had occasionally experienced similar symptoms in the past, and therefore would know that menstrual cramping would not immediately threaten her health. The records provided do not support that this patients symptoms meet the prudent layperson definition of an emergency.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested right heart catheterization for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient was evaluated by multiple providers, and her providers felt her likelihood of having pulmonary hypertension was low.  Per the submitted documentation, all other cardiac testing was essentially negative. There is a lack of support for the requested right heart catheterization at this time, as she does not have progressive symptoms or a change in clinical status.  Standard medical practice supports repeat echocardiogram in this clinical setting.  All told, the requested right heart catheterization is not medically indicated 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Xenical (orlistat capsule 120 mg). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees obesity. At issue in this case is whether the requested medication Xenical (orlistat capsule 120mg) is medically necessary for treatment of the enrollees medical condition.According to the FDA, Xenical is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia). The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30kg/m or a BMI of 27-29.9 kg/m with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. After started treatment with a weight loss medication such as Xenical, the patient should be monitored for weight loss, blood pressure, and heart rate on a weekly basis for four weeks and then monthly for the next three to four months. If patients do not lose 4 to 5 percent of body weight after 12 weeks of tolerated maximum-dose therapy, the drug should be tapered and discontinued. In this case, the documentation does support that the patient has been treated with Xenical for obesity. He has lost between 4-5% of his body weight after six months of therapy. Furthermore, the clinic has changed the type of scales and this may give inaccurate measurements of weight. It is medically reasonable to continue Xenical for further weight loss, therefore the request for the medication is considered medically necessary.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 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 parent of a 14-year-old male enrollee has requested  inpatient psychiatric hospitalization services for treatment of the enrollees psychosis, not otherwise specified, and major depression with psychotic features.    Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was admitted on the specified date with thoughts of not wanting to live and having made a statement of wanting to kill himself.  There was reference to an imaginary friend who had angry thoughts, with the clinical feeling that this may indicate paranoid delusions.  However, the patient insisted that this friend was not imaginary, and the parent thought that this might be someone the patient had actually met.  By the subsequent date, the patient denied suicidal or homicidal ideation.  He did not demonstrate himself to be a threat or dangerous towards others, and he was described as appropriate and calm in group notes.  He did not demonstrate aggressive behavior during the course of his hospitalization.  Inpatient hospitalization would not have provided additional benefit for the patient as of the date indicated.  All told, inpatient psychiatric hospitalization services provided from the time period specified were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, tomosynthesis to screen this patient for breast cancer was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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 55-year-old female enrollee has requested for facet joint injections for treatment of her back pain. Findings:  The physician reviewer found that the documentation clearly demonstrates good evidence for facet mediated pain and a reasonable response to the injections. The patient has failed other medical and conservative therapy and given her co-morbidity is not a good surgical or heavy exercise regimen candidate. It is clearly documented in the literature by Cohen et al., and Manchikanti et al., as well as accepted practice standards that intra-articular facet injection is inferior diagnostically to medial branch blockade, and inferior therapeutically to appropriately performed rhizotomy.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for H.P. Acthar Gel 80 units, two to three times per week, two vials per month, for one year. Sarcoidosis is a disease that can involve any organ, but most often affects the lungs. In cases of worsening sarcoidosis, steroids are the first-line of therapy. Of note, some patients are not responsive to steroids, as in this case. Also, steroids have many unwanted side effects. H.P. Acthar Gel is appropriate for the treatment of sarcoidosis. This medication has been demonstrated to be beneficial for patients with this condition. The potential benefits include increased six-minute walking distance, improvement in positron emission tomography/computed tomography (PET/CT) findings and lowering of the dose of chronic steroids. Therefore, H.P. Acthar Gel 80 units, two to three times per week, two vials per month, for one year are medically necessary 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 internal medicine with sub-specialty certification in pulmonary 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 patients parent has requested authorization and coverage for social skills training and center-based applied behavioral analysis (ABA) services. Based on the presenting information, center-based ABA services are medically necessary, while the social skills services are not medically necessary for this patient. Center based ABA services meet the definition of medical necessity outlined by Papatola and Lustig. In this case, the patient meets the criteria for ABA treatment, which focuses on the patients deficiencies. In addition, ABA is having the strongest evidence-base supporting its efficacy for the treatment for autism. Moreover, ABA rendered in home setting has not led to adequate progress of the patient. Given this information and his low assessment scores, a clinic setting is appropriate. However, the patient does not yet possess the prerequisite skills to participate and advance in social skills training sessions. Considering these factors, the requested center-based ABA services are medically necessary, but social skills training is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a licensed BCBA, is board certified in psychology, 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.