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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera (dimethyl fumarate).The submitted documentation supports that the requested medication is medically necessary. Tecfidera (dimethyl fumarate) is indicated for the treatment of patients with relapsing forms of multiple sclerosis at a starting dose of 120 mg twice daily for one week, followed by maintenance dosage of 240 mg twice daily. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis include respecting and evaluating patient preferences to improve acceptance of and adherence to DMTs. Patient preferences may include the safety, route of administration, lifestyle, efficacy, common adverse effects, and tolerability in the choice of DMT. In two large trials, an oral formulation of dimethyl fumarate (BG-12) significantly reduced relapse rates and the development of new brain lesions on MRI in patients with active multiple sclerosis. The safety of the three oral agents approved by the Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis were reviewed by researchers, and they concluded that the main risks marked with dimethyl fumarate were flushing and gastrointestinal events.In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis. The provider presented and weighed options for DMT and determined that Tecfidera would be most effective, considering the route of administration, its efficacy and safety for the patient, and the patients preference to avoid injectables. Based on the current medical literature, Tecfidera has an efficacy that is superior to or comparable with the other approved DMTs such as Extavia, Glatopa, and Gilenya, and its safety profile is potentially less harmful than Gilenya, the other oral alternative. Therefore, the requested medication, Tecfidera (dimethyl fumarate), is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) for evaluation of his medical condition. Findings:  Two physician reviewers found that the medical evidence does not support the requested services in this patients case.  The medical records demonstrate moderately active rheumatoid arthritis.  X-rays of hands and feet show a single erosion.  The plan is to continue methotrexate and consider starting an anti-tumor necrosis factor agent.  The x-rays show evidence of erosive disease.  It is unclear from the record how an MRI would impact the patients treatment.  Thus, the requested MRI is not likely to be more effective than other modalities for evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in rheumatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the right knee. Review of the submitted documentation supports the medical necessity of the requested Orthovisc injections in this case. The relevant literature reveals that hyaluronic acid (such as Orthovisc) was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of various studies. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Further, nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines state that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronic acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. In sum, evidence-based peer-reviewed literature supports the use of viscosupplementation injections such as Orthovisc for the treatment of pain in patients with severe osteoarthritis of the knee. Viscosupplementation allows for delay of total knee replacement and is more efficacious than corticosteroid injections. In this case, the patient has been diagnosed with advanced (bone-on-bone) osteoarthritis of the right knee. The patient has current extreme right knee pain and functional impairment in activities of daily living that has failed to respond adequately to other conservative treatment. She wants to delay total knee replacement and has reported positive results with hyaluronic acid injections in the past. Therefore, the requested Orthovisc injections for the right knee are medically necessary for treatment of 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 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

The parent of a 14-year-old male enrollee, with idiopathic short stature, has requested authorization for growth hormone therapy. Findings:  The physician reviewer found that the patients growth rate dramatically accelerated after GH therapy was initiated at Tanner stage 2 of his development. His growth response is recorded at 13.6cm/yr when 14.5 years of age.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections.  Findings:  The physician reviewer found that evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  This has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient been diagnosed with left knee tricompartmental osteoarthritis, bone-on-bone in the medial compartment.  She had failed to adequately respond to other conservative treatment, including anti-inflammatory medications, steroid injections, and bracing.  Prior viscosupplementation injections resulted in significant benefit, allowing resumption of normal activities.  The patient has requested Euflexxa injections to reduce pain, improve function, and delay total knee replacement.  There is sufficient support for the requested services in this clinical setting.  All told, the requested Euflexxa injections are medically indicated for the treatment of this patient. 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 physician 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 56-year-old female who has a long-term history of low back pain. She has had multiple sessions of physical therapy (PT) with only mild, temporary improvement. Her provider indicates her correct diagnosis is sacroiliitis although previous treatment was for lumbo-sacral disc disease. MRI reveals mild to moderate stenosis of the central canal at L1-2. The patient had approximately three months of PT in 2005 and approximately two months in early 2006. The patients request for additional PT was denied by the Health Plan citing a lack of medical necessity.The physical therapy previously provided does not seem to have had any lasting impact on the patients condition and the documentation submitted does not suggest that a new treatment modality will be implemented. Although the provider indicates that treatment should now address sacroiliitis in addition to low back pain, therapy for sacroiliitis generally involves the same treatment modalities as for back pain. It does not appear that additional physical therapy would likely result in an improved clinical outcome for this patient. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested breath hydrogen or methane test for evaluation of the enrollees dyspepsia.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patients symptoms and medical work-up are reassuring for the absence of an inflammatory, progressive, or life-threatening condition.  The medical records suggest a functional condition akin to irritable bowel syndrome (IBS).  While small intestinal bacterial overgrowth (SIBO) may exacerbate symptoms of IBS, lactulose breath testing is not a reliable means of determining whether SIBO is present or whether treatment of SIBO is liable to lead to symptom improvement.  There is a lack of standardization for interpretation of breath tests, with inconsistent criteria for which breath hydrogen and methane parameters constitute a positive result.  Additionally, there is a lack of correlation between breath hydrogen or methane production on testing and the presence of abdominal pain and IBS phenotype.  In sum, there is a lack of support for the requested services in this clinical setting.  All told, the requested breath hydrogen or methane test is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested 12 hours of direct applied behavioral analysis (ABA) therapy per week and 8 hours per month of supervision for treatment of his autism. The physician reviewer found that review of the submitted documentation demonstrates this six-yearold patient is autistic.  By specific Vineland Adaptive Scale scores, his age equivalency has shown only minimal improvement, but he achieved most of the behavioral goals outlined by his therapists over the past two years. This is typical of autistic children, as it is extremely difficult to test this patient population at a single setting. For test scores to be reliable, they generally have to be repeated over a short span of time.  However, since the patient has met most of the outlined behavioral goals, he has demonstrated positive improved behavior which is one of the major goals of ABA therapy. Despite the patients slow improvement in response to ABA therapy over the prior two years, ABA therapy remains the mainstay treatment in this setting. It is the medical communitys customary practice to provide ABA services to a child with autism. There is strong support in the medical literature establishing ABA therapy and Picture Exchange as the only peer-reviewed successful treatments for autism. ABA therapy has a well documented history of substantially improving motor, verbal, and interactive social skills in this population. Myers and Johnson state: The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. That ABA therapy is the treatment of choice for autistic children is confirmed in multiple controlled studies including the studies by Turner, Sallows and Remington cited above. These studies also emphasize that ABA intervention should be initiated and continued at an early age. This patient has been diagnosed as autistic and continued ABA therapy is medically appropriate and indicated.Based upon the relevant literature, as well as the progress and continued deficits documented in the patients clinical records, continued ABA services are medically necessary for this patient. However, after two years of therapy, a reduction in the frequency of services to 10 hours of direct 1:1 therapy per week and 4 hours per month of supervision is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oral device/appliance procedure. Researchers note that the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) recommend the prescription of oral appliances and periodic office visits for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy. In this case, the patient has moderate obstructive sleep apnea post tonsillectomy and pharyngoplasty, and is intolerant to CPAP. Given that the patient remains symptomatic, the requested equipment is medically indicated. Therefore, oral device/appliance procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 sleep 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: Overturned

The parent of a 16-year-old male enrollee has requested jaw reconstruction surgery with dental implants for treatment of ectodermal dysplasia.Findings:  The physician reviewer found that the proposed reconstructive surgery is designed to restore defects, both functional and morphogenic, that are due directly to the congenitally inherited disease of ectodermal dysplasia. This intervention is not designed to restore structure or function that was lost due to dental disease, dental caries or periodontal disease. Therefore, bone augmentation and placement of dental implants is medically reasonable and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested outpatient psychotherapy visits 4 times per week for treatment of her major depressive disorder with history of suicide attempt.  Findings:  The physician reviewer found that based on review of the available records, this patient has a history of major depression recurrent, and schizoid personality disorder and has been in therapy 4 hours per week since this year. The documentation presented by the provider showed a patient with chronic suicidality with intense feelings of hopelessness. This patient has apathy and listlessness with a strong family history of depression. The patient appears to be socially isolated and appeared to improve with therapy at times but then would slip back into the pattern of hopelessness and strong depressive symptoms. The records suggest that this patient has shown some response to psychotherapy on an outpatient basis utilizing dialectical behavioral therapy (DBT) and cognitive behavioral therapy (CBT). The medical literature supports the efficacy of DBT and a CBT for the treatment of this patients depression. Although the benefits of long-term outpatient therapy remain varied, this patient has been safely and adequately treated on an outpatient basis. As such, individual psychotherapy appears to be medically necessary at the frequency of 4 times per week since the date in question and forward for management of this patients depression and personality disorder.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve surgery for treatment of her enrollees obesity. Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested surgery. In this case, the patient is obese and has failed dietary efforts, including supervised weight loss. However, based on standards guidelines by the American Society for Metabolic and Bariatric Surgery, the criteria requires documentation of a behavioral/psychological evaluation as well as a dietary evaluation specific for bariatric surgery. A dietary evaluation and psychological evaluation were not submitted for review. There was also no surgical evaluation provided for review. A multidisciplinary evaluation is considered a standard component to determining if an individual is an appropriate candidate for bariatric surgery. Final Result: The reviewer determined that the requested surgery 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 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 33-year-old female enrollee has requested psychiatric treatment services she received from a non-plan provider.  Findings:  The physician reviewer found that the patient was hospitalized on a 5150 involuntary hold followed by a 5250 hold due to an altered sense of consciousness and paranoid delusions. Since the police initiated the 5150, and a 5250 was also authorized, the patient had no control over her hospital stay. The difficulty in transporting a paranoid patient on a 5250 to another hospital is significant.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee requested surgical implantation of naltrexone for medical treatment of her alcohol dependence.  Findings:  Three physician reviewers found that although naltrexone was appropriate and reasonably expected to improve the patients condition and foster longer-term recovery, the particular delivery method was not likely to be more beneficial than any available standard therapy, namely oral or intramuscular preparations of naltrexone.  The medical documentation did not suggest that adherence to oral medication was problematic in this case. All told, the superior efficacy of surgical implantation of the medication naltrexone has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for general anesthesia.Among their listed indications for general anesthesia for pediatric dental patients, the American Academy of Pediatric Dentistry state that general anesthesia is indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity, the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent, and patients requiring immediate, comprehensive oral dental care. In this case, the patient has a documented history of previous difficulty with dental procedures and was intolerant of basic dental examinations. The submitted records also document an attempt to provide restorative care to the patient using nitrous oxide which had to be stopped due to the patient not tolerating the procedure. Therefore, standard behavior guidance techniques have failed, attempts to treat the patient under moderate sedation with nitrous oxide have failed, and the required restorative work is extensive and involves four quadrants of the mouth. Under these circumstances, the requested general anesthesia is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.