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

A 66-year-old male enrollee has requested general anesthesia for dental procedure (Tori removal) for treatment of his dental anxiety. Findings: The physician reviewer found that based on review of the available records, general anesthesia for extensive dental services and a high level of anxiety is not medically necessary. This patient does not present with a significant history that would require monitored anesthesia care. Additionally, there is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for general anesthesia. In the medical literature, Shabanie reported that sedation could be categorized into minimal, moderate. or deep sedation with general anesthesia. Sedation may add a new dimension to procedures by compromising the patients normal protective mechanisms and carries the potential of cardiac, respiratory, and cognitive complications. The author stated that interventional procedures could be performed under local anesthesia, with or without sedation, or under general anesthesia. The choice generally depends on patient factors such as age, cardiovascular stability, pain tolerance, and procedural factors such as complexity, extent, and degree of induced pain. In longer and more extensive procedures on more fragile patients, the assistance of an anesthesiologist will be required. Hausman and Reich noted that not all procedures are well suited for the office with sedation. Examples of such procedures would include those associated with significant fluid shifts, postoperative pain, bleeding, or procedures of long duration. However, relatively non-invasive procedures, those of short duration, and those not associated with either fluid shifts or significant post-procedure discomfort, are well suited to office-based practice without sedation. Consistent with these findings, the requested general anesthesia for Tori removal is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested  acute inpatient psychiatric treatment for treatment of the enrollees behavioral health problem.  Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient was clearly and acutely unstable at the time of his admission. He has a history of violence and around the time of his admission, his anger and agitation escalated to the point of injuring his brother and damaging items in the home. He was appropriately medicated and stabilized from the beginning of treatment. He had early and sufficient family therapy sessions. The patient was sufficiently stable to transition to a less intensive level of care. The documentation thereafter indicates that the patient remained in the facility due to the unavailability of an appropriate lesser level of care. Thus, continued acute inpatient level of care was not medically necessary. Further, the medical necessity of re-admission to an acute inpatient level of care is not supported by the medical records provided. The medical record documentation demonstrates that the patient was alert and oriented. His insight and judgment were noted to be improving and impulse control was described as very fair. He denied auditory hallucinations and no delusions were noted. The providers assessment was that the patient was stabilizing and appropriate for discharge with follow-up and medication management on an outpatient basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with dyslipidemia, coronary artery disease, cardiomyopathy, and paroxysmal atrial fibrillation. Laboratory results revealed a cholesterol level of 225 mg/dL, a low-density lipoprotein (LDL) level of 122 mg/dL, and a high-density lipoprotein (HDL) level of 87 md/dL.  The provider noted the patient previously had tried atorvastatin and ezetimibe, which were both not tolerated due to muscle aches and cramping. A cardiac catheterization report revealed an ejection fraction of 30 to 35%, severe coronary disease of the left anterior descending artery and moderate disease of the ostial left main coronary artery. A stent was placed. The patient denied angina, dyspnea, syncope, and edema. The patient has requested authorization and coverage for a Repatha Sureclick 140 mg/ml pen injector. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Repatha Sureclick 140 mg/ml pen injector is medically necessary for the treatment of the patients medical condition. Grundy and colleagues reported, At a median follow-up of 2.2 years, evolocumab significantly reduced composite atherosclerotic cardiovascular disease (ASCVD) without neurocognitive side effects. In this case, the patient has established coronary artery disease and ischemic cardiomyopathy. The patient is status post left anterior descending coronary artery stenting. He has tried and failed statin therapy in the past with atorvastatin and ezetimibe, both of which were not tolerated due to joint and muscle aches. The patients LDL level in December 2019 was 122 mg/dL. The medical evidence supports the requested medication in this clinical setting. Therefore, a Repatha Sureclick 140 mg/ml pen injector is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the 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 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

The parent of an 11-year-old female enrollee has requested weekly cognitive behavioral therapy (CBT) for treatment of the enrollees obsessive compulsive disorder and anxiety disorder. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Current psychiatric practice is focused on the aggressive treatment of anxiety disorders in the acute phase of the illness, followed by less frequent services and greater community involvement, in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for anxiety disorders. The American Academy of Child and Adolescent Psychiatry (AACAP) strongly recommends CBT as a first line treatment for mild to moderate cases of OCD in children. A definitive study by the National Institute of Mental Health, which is referenced in the AACAP practice parameter, identifies 14 visits over 12 weeks of CBT with exposure and response prevention as appropriate treatment for youth plagued with OCD. Considering this patients diagnosis and disease burden, the therapy in dispute is safe, appropriate and consistent with good medical practice.  Thus, weekly CBT is medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested Morphine 60mg tablets, 3 tablets, four times a day, which equates to 720mg a day and Norco 10/325 tablets, four times a day for treatment of his chronic pain.   Findings:  The physician reviewer found that Baron and colleagues reported high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It would be in the best interest of the patient to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the his chronic pain.High dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Morphine 720mg a day and Norco 10/325 mg tablets, four times a day is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old male who had a middle cerebral artery stroke in April 2006 followed by an occipital-parietal hemorrhage in April 2006. He transferred to the acute rehabilitation setting in April 2006. The level of rehabilitation progress achieved with physical therapy is unclear, but apparently was minimal as he required maximal assistance upon admission to the skilled nursing facility (SNF) in May 2006 with a dense right hemiparesis and significant deficits. PT, OT and ST report progress while he was receiving services at the SNF, but the level of progress with PT is not clearly documented. On the other hand there was clear progress with OT and ST, although quite modest as would be expected. With OT he had improvement in lower body dressing and in grooming progressing from a requirement of moderate assistance to a requirement of minimal/moderate or minimal assistance. ST reports the patient was initially unable to generate any distinct sounds, but was able to produce consonant and vowel sounds in combination and respond appropriately, though nonverbally, to inquiries with the benefit of therapy.The patient has requested authorization for skilled nursing facility services including OT, PT and ST. The Health Plan denied the request based upon a determination that the services are not medically necessary.The patient had a severe stroke resulting in severe deficits. The degree of functional recovery is likely to be modest and the rate of recovery will be slow. However, he was progressing with OT and ST and there is some evidence he was progressing with PT, but the specifics are not entirely clear. It does not appear from the records that the patient had yet achieved his maximal functional recovery, and the preponderance of evidence showed that he was progressing modestly. Rehabilitation services should be resumed and continue for as long as there is demonstrated functional gain.Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 100 hours per month of direct one on one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision by BCBA and four hours per month of caregiver training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for ABA therapy at the frequency of 100 hours per month of direct one on one therapy, 14 hours per month of supervision by BCBA and four hours per month of caregiver training has been established as medically necessary. In this case, the patient has made improvements, however he continues to have issues with noncompliance, tantrum, crying/whining and object mouthing. Therefore, based on the records submitted for review the requested services are medically necessary for treatment of the patients autism. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test performed Findings:  The physician reviewer found that there is currently insufficient medical evidence to support the effectiveness of Prometheus Anser VDZ testing compared with conventional courses of action in the management ulcerative colitis. The published studies regarding the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the antibodies can be transient .  Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, there is insufficient evidence from controlled studies to definitively demonstrate that the blood test performed was likely to be more beneficial for evaluation of the patients ulcerative colitis than any available standard therapy.Final Result: All three 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 reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 15 pills per month of Cialis for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. This patient has a history of erectile dysfunction following pelvic fracture. His provider has recommended Cialis. The patient has requested coverage for 15 pills per month of Cialis. The Health Plan has approved coverage for six pills per months as an alternative. The use of six tablets per month is an appropriate supply for the treatment of this patients medical condition. The records do not support the medical necessity of the requested medication quantity in this patients case. All told, the requested 15 pills per month of Cialis are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronate gel injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. However, this patients records document that after he completed a series of five hyaluronic acid injections, he presented with complaints of severe knee pain, indicating lack of efficacy in this case. Overall, the records indicate that this patient has undergone two series of hyaluronic acid injections in both knees without substantial relief. Thus, the requested hyaluronate gel injections are not supported as medically necessary for treatment of this patients osteoarthritis. 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 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: Upheld

The patient is a 39-year-old male who underwent evaluation with polysomnography for suspected obstructive sleep apnea. In a letter from the patients physician it is noted that the patient has a history of hypersomnia, as well as excessive daytime sleepiness. The information submitted does not indicate any other associated symptoms or findings such as witnessed apneas, mood disorder, cardiovascular disease or hypertension. Polysomnography performed on 8/8/04 shows an AHI of 2.8 with an oxygen saturation nadir of 92% during a total sleep time of approximately 86 minutes. The subsequent CPAP titration study shows an AHI of 1.3 with oxygen saturation stable above 90%  total study time was 314 minutes. Sleep efficiency for the initial study was calculated at 25.4% with sleep efficiency for the titration study calculated at 86.5%. Periodic limb disorder was also noted in the titration study with a PLM arousal index of 32 episodes per hour. The patient is on Klonopin, although there is no indication for what purpose. In addition, early on during the CPAP titration study, the patient was given Ambien 10mg. The patient has a body mass index of 24. He is seeking authorization for CPAP.Although this patient has symptoms of excessive daytime sleepiness, he does not meet currently accepted criteria for the diagnosis of sleep apnea. Current Medicare guidelines support the use of CPAP in patients with mild obstructive sleep apnea (AHI 5-15) with excessive daytime sleepiness. However, this patients AHI is 2.8. He also does not have significant oxygen desaturation. The numbers for improvement in sleep efficiency between the initial polysomnogram and the titration study are significant in this case, but changes in AHI are minimal and oxygen saturation was not improved during the titration study. It may be that sleep efficiency calculation improved secondary to the patient taking Ambien at the start of CPAP titration. Based upon this information, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Subsys for the treatment of his medical condition. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The records do no demonstrate that non-opioid treatment options have been exhausted. Behavior therapy has not been done, despite research to support its use. In addition, optimization of all non-opioid medications has not been documented.  The records demonstrate that tolerance has taken place.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. The records do not demonstrate a plan in place to monitor this patient with the new increase in medications.  There is a lack of support for the requested medication in this clinical setting. All told, Subsys is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Advair 500/50. Advair is the combination of fluticasone, an inhaled corticosteroid (ICS), and salmeterol, a long-acting B2 agonist (LABA). The National Institutes of Health Guidelines from the National Asthma Education and Prevention Program note that treatment of asthma involves a sequence of steps up or down based upon the patients response and severity of the disease. The recommended initial treatment for mild intermittent asthma, less that two episodes weekly, is a short-acting beta agonist (SABA) which can be stepped up to combination therapy with an ICS and a LABA. Options for combination ICS and LABA therapy include Advair and generic versions, Symbicort, Flutiform, Seretide metered dose inhaler (MDI) versus Accuhaler, Dulera and Breo Ellipta. Longphre and colleagues note a clinical bioequivalence of Advair Diskus to its generic version. In this case, the patient has mild intermittent asthma that is well controlled and would benefit from treatment with a combination ICS and LABA therapy. Current medical literature does not endorse brand-name Advair over generic alternatives. Therefore, Advair 500/50 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care 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 50-year-old male enrollee has requested for Supartz injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation has been generally accepted as part of the treatment of osteoarthritis of the knee, it has been found to be more effective in patients with non-radiologically severe disease. Viscosupplementation is most suitable for patients with mild to moderate osteoarthritis.  Further high-quality randomized controlled studies are needed to define the role of these injections in the treatment of osteoarthritis.  In this case, the patients osteoarthritis is described as severe. In addition, no benefit has been delineated for the use of Supartz in contrast to other hyaluronans.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.