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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation (CPT 78816). Erdheim-Chester disease most commonly manifests as multifocal sclerotic lesions of the long bones demonstrating sheets of foamy histiocytes on biopsy, with or without histiocytic infiltration of extra-osseous tissues. A patients baseline disease status, organ involvement, and requirements for ongoing treatment direct the frequency and mode of imaging. PET/CT is a preferred imaging modality in this clinical setting as it can assess extra-osseous involvement. Bone scintigraphy can demonstrate the iconic radiologic features but does not assess extra-osseous involvement. PET/CT is helpful to evaluate the cardiovascular system and allows visualization of the entire vascular tree during a single session. This patient has extensive disease involving the nodes and is on a clinical trial. A prior PET/CT showed stable innumerable bone lesions. The provider recommended a PET scan with CT for attenuation to track the patients progress and response to treatment. Given these findings, the requested PET with CT for attenuation (CPT 78816) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 the medication Nucynta. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees fibrous dysplasia and back pain. At issue in this case is whether the requested medication Nucynta is medically necessary for treatment of the enrollees medical condition.Nucynta (tapentadol) is an opiate agonist that is also a norepinephrine reuptake inhibitor. There is little published data to support the use of tapentadol in the tapering of pure agonist opiate therapy. The package insert speaks to a gradual reduction in the dose by 25 percent per step. Too rapid a taper can result in the opiate withdrawal syndrome. Opiate dose conversion calculators also give a wide range of equivalents, because of genetic factors, incomplete cross-tolerance and pharmacokinetics. Other pure agonist opiates have more supporting data that are on formulary as well as opioid withdrawal attenuation cocktails. Therefore, the requested medication is not 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for home health nursing services of 88 units per month of home health aide services and 48 units/month of home licensed vocational nursing services. The enrollee has type 2 diabetes mellitus, pain in the right knee, paralysis of one side as a result of a stroke, moderate chronic kidney disease, and chronic pain syndrome. The enrollee receives skilled nursing services for medication management and teaching. Per records, a certified home health aide is needed for bathing assistance one to times per week. Literature shows the process for determining the necessity of home health services includes an evaluation of the persons need for services. Medical records do not support the need for such services for this enrollee. Medical records show this enrollee has weakness, but no inability to perform activities of daily living. The medical records did not show the enrollee continues to have a medical problem that needs special care which can only be provided by skilled individuals. The enrollee is noted to need assistance with bathing and in the community. These services can be provided by an unskilled individual and do not require a nurse or home health aide.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested mental health acute inpatient treatment program services for  her behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, by the date in question the patients symptoms had become stable enough for a lower level of care. The acute episode of catatonic and bizarre behavior had resolved. She was described as more cooperative with her care and interactive with peers. Although she continued to believe that nurses were reading her mind, this appears to be a longstanding issue. Her ritualistic and compulsive behaviors had decreased. She has a supportive home environment with her family. The patients symptoms had stabilized and further services could have been safely provided in a less intensive setting. Clozaril dosage, side effects, and monitoring of complete blood counts could have been safely monitored in an office-based setting. In sum, her condition as of the said date was not severe enough to warrant 24-hour supervision in an inpatient setting. Thus, continued inpatient stay from the date in question onward would be considered to be custodial in nature.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Executive Function education therapy by an education therapist for treatment of the enrollees autism spectrum disorder.Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested therapy in this clinical setting. At this time, executive function training requires further evaluation through well-planned clinical trials to assess its efficacy and long-term outcome. There is currently a lack of definitive evidence in the form of multiple reproducible randomized clinical trials that demonstrates the long-term utility of this therapy in adults with autism spectrum disorders. In addition, the use of Executive Function education therapy has not been definitively proven to be useful in short-term studies of children with autism spectrum disorders. Final Result: Two reviewers determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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

The patient is a 38-year-old woman who has requested continuation of long-term intravenous immunoglobulin (IVIG) therapy for hypogammaglobulinemia and an unnamed autoimmune disorder. The records from the patients previous physician document the ongoing use of IVIG, as well as prednisone in unclear doses, but without any clear indication stated. The Health Plan has denied the patients request indicating that the submitted documentation does not demonstrate that the requested therapy is medically necessary.The data provided does not establish the patients diagnoses or provide any clear indication for treatment with IVIG. Hypogammaglobulinemia is not described nor documented in the provided records and there is no explanation for the initial use of IVIG in this patient five years earlier. There is no evidence given of recurrent or significant infection. The patients current treating physician has not recommended that IVIG be continued. In addition, the patients IgG levels were variable, with only one reading below normal. Furthermore, although the records suggest that the patient is being treated with prednisone for a connective tissue disorder of unclear origin this is neither described nor supported. It does not appear the patient has been examined by a rheumatologist to address this issue. She is reported to have diabetes mellitus as well, but any relationship between this diagnosis and her prednisone treatment is unstated.Thus, the submitted documentation provides no clear evidence of hypogammaglobulinemia or an autoimmune disorder, which would necessitate the continuation of IVIG therapy. The alternative approach of continuing management by the patients current hematologist/oncologist is medically appropriate. Therefore, I have determined that 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

The patient is a 51-year-old woman with pain in the right temporomandibular joint (TMJ) and right-sided muscles of mastication. Also noted among her symptoms was reciprocal clicking with range of motion in the right TMJ. Her diagnoses were: right-sided articular cartilage disorder, right-sided TMJ capsulitis and right-sided facial/cervical myositis.  The patient received services in September 2005 for which she is now requesting reimbursement.  The Health Plan denied her request based upon a determination that the services she received were not medically necessary.  Following the September 2005 consultation, the patients provider submitted a plan of treatment directed toward the general goals of avoiding surgery and reducing pain, inflammation and adverse joint loading. There were no specifics with respect to radiographic findings, treatment notes, metrics of progress or the need and design of an interdental fixation device. This type of device is usually employed for management of jaw fractures, dental trauma or postoperative splinting following orthognathic surgery.  The clinical rationale for the use of the interdental fixation device in this instance has not been provided.  More commonly, a dental occlusal splint would be applied in this type of circumstance.  Electrical stimulation and manual therapies were also provided in September 2005. The clinical documentation does not explain the medical/dental basis for these therapies; and they are considered experimental and not supported in the literature.  Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan injections every six months (right knee). An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is a history of significant pain relief from prior viscosupplementation. Oral and topical NSAIDs were not effective. Additionally, the patient reported side effects from corticosteroid injections. Therefore, hyaluronan injections every six months (right knee) are medically necessary 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for group speech therapy with the enrollees peers, that excludes children nine years and younger. Findings:  The physician reviewer found that the request for group speech therapy, that excludes children nine years and younger is medically necessary for this patient. There is medical literature demonstrating that social skills groups can improve social competence for some children and adolescents with autism. In this case, the patient has mastered social interactions with younger peers. As such, group speech therapy that excludes children younger than nine years is clinically indicated to have the patient develop social goals of interacting appropriately with same age peers. Therefore, the requested services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental and 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: Medical Necessity
Decision: Upheld

The patient is a 38-year-old male with L1 paraplegia who has been receiving outpatient physical therapy for one year. He has requested further physical therapy to improve his level of functioning. The Health Plan has denied authorization and coverage for continued therapy indicating the requested therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The patient has not recently demonstrated significant functional gain per the physical therapy note of June 2005. At this time the patient seems to have plateaued in physical therapy. The patient and his family should be independent in a home exercise program, which should be performed two times daily at minimum. Follow-up consultations with the patients spinal cord injury specialist should be performed to determine any change in rehabilitation potential. However, at this time there is no clinical indication for continued physical therapy. Therefore, I have determined that 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: Overturned

A fifty-four year-old female who underwent an anterior cruciate ligament (ACL) reconstruction is requesting authorization for a continuous passive motion (CPM) machine.  Reviewers Findings:The reviewing physician found that a CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction, making the CPM medically appropriate.   The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested artificial disc replacement surgery for the treatment of his chronic low back pain radiating into the legs. Findings:  Three physician reviewers found that painful lumbar disc degeneration is usually treated with fusion after failure of non-surgical treatment. Due to the value of preserving motion and reducing degenerative changes in adjacent segments, artificial disc replacement is currently being studied. However, as noted by de Kleuver and colleagues, at this time there is a lack of evidence regarding the efficacy, reproducibility or long-term survival of these prostheses. Gamradt and Wang report that despite the presence of positive early clinical results, studies describing the maintenance of motion and durability of the discs over the long-term have not yet occurred. German and Foley note that the effect of these implants on adjacent level disc degeneration is also not known. Freeman and Davenports review of the scientific literature suggests that well designed, prospective, randomized, controlled studies are still needed to evaluate this technology. Some studies are in progress, but the results are not yet available; therefore this procedure remains of unproven efficacy for the treatment of back pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement, authorization, and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the services at issues were not and are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the intensive outpatient program (IOP) services were and are medically necessary for treatment of the patients behavioral health condition. The patient began the intensive outpatient program services. The progress notes do not reflect severe regular emotional outbursts or other issues that would warrant intensive treatment. The progress notes indicate the patient is mostly cooperative in treatment but is often sarcastic, and is not very invested in treatment. The treatment goals are largely related to chronic issues of disrespect.The patient is not aggressive with anyone in the program and does not exhibit emotional or physical outbursts during the IOP sessions. Her mood is relatively stable throughout her sessions. The major issues are her relationship with her parents and disrespect towards them. She has not expressed any suicidal or homicidal ideation or psychosis. She was noted to be free from suffering behaviors for over six months. The records do not indicate that she has used any substances during the dates at issue. Therefore, the intensive outpatient program services were not and are not medically necessary.Final Result: The reviewer determined that the requested services 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 subspecialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  For cirrhotic patients, the efficacy of Harvoni has been well-demonstrated.  By virtue of her compensated cirrhosis, this patient meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for immediate treatment with the highest priority.  However, the Health Plan has offered coverage for Viekira Pak which is equally efficacious in this setting.  As such, the medical necessity of the requested medication Harvoni for 12 weeks as opposed to the alternative Viekira Pak has not been established.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 certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz extended release. Findings:  The physician reviewer found that current peer-reviewed medical literature, Xeljanz has not been shown to be safe and effective for the treatment of Crohns disease based on well-designed randomized controlled trials. There are studies demonstrating the safety and efficacy of Xeljanz in patients with ulcerative colitis. However, the data has not reported superior patient outcomes with Xeljanz as compared to standard available therapies in the treatment of patients with Crohns disease. Sandborn and colleagues found that Xeljanz was more effective as induction and maintenance therapy than placebo. However, the authors also noted that Xeljanz was associated with increased lipid levels. Given these data, additional studies are needed to assess the clinical role of Xeljanz, if any, in the treatment of Crohns disease. All told, the requested Xeljanz extended release is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz extended release is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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.