Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested the Dynasplint system (E1810) for treatment of her medical condition status post open reduction with internal fixation.  Findings:  Three physician reviewers found that in the peer reviewed literature, Stephenson and colleagues demonstrated that mechanical therapies combined with physical therapies significantly reduced rates of re-hospitalization in an elderly population who had had total knee replacement. Similarly, Dempsey and colleagues highlighted the importance of treating knee flexion contractures and presents a convincing argument that adjunctive use of mechanical therapies is an effective option for patients with knee flexion contractures. The patients studied had all reached a plateau when treated with physical therapy alone. The authors concluded that, We conclude that the adjunctive use of [high intensity stretch] HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures. Given this patients presentation, it was in her best interest to use the low intensity stretch mechanical treatment (Dynasplint) for her likely diagnosis of arthrofibrosis of the knee following lateral tibial plateau fracture. The medical records describe a prompt open reduction internal fixation requiring both homograft and allograft for a depressed lateral tibial plateau fracture. This fracture has a very poor prognosis because of the involvement of the joint surface. Due to this patients young age, it is important the treatment protocol be maximized. The records document a good response to post-operative physical therapy, CPM and low intensity stretch techniques, thus the addition of the Dynasplint was appropriate and should be reimbursed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for diagnostic laparoscopy and bilateral oophorectomy/salpingectomy. Findings:  The physician reviewer found that Laparoscopy with bilateral oophorectomy/salpingectomy is indicated in specific clinical scenarios for ovarian pathology, including malignancy, torsion, and certain ovarian cysts. Chronic pelvic pain with no ovarian pathology on imaging is not a clinical indication for bilateral oophorectomy/salpingectomy. The submitted documentation does not support the medical necessity for  the requested services in this patients case. Therefore, diagnostic laparoscopy and bilateral oophorectomy/salpingectomy are not medically necessary for treatment of the patients medical condition.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 obstetrics and gynecology 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 representative of an 84-year-old female enrollee has requested for Somazina for treatment of the enrollee, who is status post intracerebral hemorrhage. Findings:  The physician reviewer found that the medical literature does not indicate that this medication is likely to improve outcomes in this clinical situation.  The current literature shows that this medication is likely to be safe.  However, the efficacy of the requested medication has not been established at this time.  In a small trial by Secades and colleagues, the authors examined the efficacy of this medication in intracerebral hemorrhage.  The authors reported that although this medication appears to be a safe drug for intracerebral hemorrhage, with a positive trend regarding efficacy, these data should be confirmed in a larger trial.  All told, Somazina is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Fentanyl transdermal patch for treatment of her medical condition. Findings:  The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In this patient, the submitted records do not indicate that all non-opioid treatment options have been utilized. Further, the submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. In addition, the submitted documentation does not indicate an optimization of all non-opioid medications. Moreover, the records reflect that tolerance has taken place since the start of the narcotics as well as dose escalation. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation; however, down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Studies reveal that such patients are worse off since they now have a much higher opioid tolerance level. Further, it does not appear there is a plan in place to monitor this patient with the medications both historically and currently.  Moreover, the submitted medical records do not discuss other standard mitochondrial myopathy treatments. Finally, multiple minimal requirements for opioid prescribing have not been met for this patient and the need to use opioids as the primary treatment strategy for pain has not been established. For these reasons, the requested Fentanyl transdermal patch is not medically necessary for treatment of the patients medical condition.   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 sub-specialty certification in pain management 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 intravenous immune globulin (IVIG). Findings:  The physician reviewer found that the medical literature does not support the use of IVIG in this clinical setting. A study  performed a dose-finding trial of two different doses of a new formulation of immunoglobulin for suppression of both clinical and magnetic resonance imaging (MRI) disease activity as well as safety. The authors concluded that this study did not substantiate a beneficial effect of IVIG in doses ranging from 0.2 to 0.4 g/kg. This result seriously questions the utility of IVIG for the treatment of relapsing-remitting multiple sclerosis. Similarly, the study for secondary progressive MS states that Treatment with IVIG in this study did not show any clinical benefit and therefore cannot be recommended for patients with secondary progressive multiple sclerosis. In this case, the patient has been treated with Copaxone. However, there is no mention that the patient has been treated with other highly active U.S. Food and Administration (FDA) approved therapies for disease modification such as Gilenya, Tysabri, Lemtrada, or Zinbryta. Thus, there are multiple disease modifying agents that are more effective than Copaxone, and likely to be effective in treating the patients progressive MS. As such, the request for IVIG 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 & 3 are board certified in neurology and is actively practicing. The reviewers 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microprocessor ankle/foot. Findings:  Two physician reviewers found that the request for microprocessor ankle/foot is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Studies report on the contributions of active ankle and knee assistance to the walking mechanics of transfemoral amputees using the powered prosthesis. Powered ankle knee prosthesis provide active knee and ankle assistance effecting the mechanics of transfemoral amputees. The authors assessed ankle stiffness during swing initiation and active powered plantarflexion in three transfemoral unilateral amputees at walking speed.  The authors investigated the effect of the powered ankle plantarflexion combined with active flexion of the knee in terminal stance and in other portions of the gait cycle. The authors found that eliminating active knee swing initiation or powered plantarflexion was linked to increased compensations of the ipsilateral hip joint during the subsequent swing phase. In this case, the patient is a traumatic amputee. The requested microprocessor controlled device will likely improve the velocity of his gait and allow him to do step over as well as step up and down stairs and minimizing the likelihood of falls. In sum, the proposed device incorporates microprocessor technology and the benefits will provide decreased energy expenditure, improved function particularly in stair climbing and descending, and in the prevention of falls. Final Result: As such, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Overturned

A 54-year-old male enrollee has requested Sovaldi (sofosbuvir) for treatment of his hepatitis C genotype 1a.   Findings:  The physician reviewer found that The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) reported that Sovaldi has demonstrated improved efficacy and tolerability in the treatment of well selected patients with chronic HCV infections. Per the guidelines, the oral route of administration and shortened treatment duration requirements support the use of Sovaldi in lieu of conventional agents in unique patients. This patient is unique as his depression makes him interferon ineligible and his human immunodeficiency virus (HIV) coinfection warrants a modification of his therapy. Further, genotype 1 patients coinfected with HIV unable to receive interferon therapy can be treated with Sovaldi 400 mg once daily and weight-based ribavirin for 24 weeks. Consistent with these findings, the requested Sovaldi is medically necessary for treatment of this patient's medical condition for the recommended 24-week course.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-one year-old female who is addicted to heroin is requesting reimbursement for chemical dependency day-treatment (partial hospitalization).  Reviewers Findings:The reviewing physician found that detoxification alone would have been inadequate in terms of longitudinal treatment. Referral of the patient to day treatment post-detoxification was entirely reasonable, as well as in line with standards of care for serious addictions.  The physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested for single-level artificial disc replacement surgery for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement surgery remains experimental for the treatment of lumbar degenerative disc disease. More long-term outcome studies are needed to establish the safety and efficacy of this treatment. Lumbar fusion is the gold standard for surgical treatment. No long-term outcome studies exist to demonstrate that artificial disc surgery is more effective in the long-term than single-level fusion.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for an open-wedge tibial valgus osteotomy with internal fixation allograft bone grafting with an osteochondral allograft OATS procedure for the left knee for treatment of her left knee osteoarthritis.   Findings:  Three physician reviewers found that the requested OATS with allograft is experimental for the treatment of knee degenerative joint disease. This procedure combined with osteotomy lacks long-term outcomes follow-up. More outcomes data is needed to establish the safety and efficacy of this procedure in this type of case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization nad coverage for obinutuzumab (Gazyva). The submitted documentation supports the medical necessity of the requested medication. This patient is requesting continuation of treatment with obinutuzumab (Gazyva) to be used in combination with ibrutinib. He received this treatment in a clinical trial. This combination was recently approved by the U.S. Food and Drug Administration as a first-line therapy for patients with chronic lymphocytic leukemia. As this patient was enrolled in the trial that lead to approval and is requesting continuation of this recently approved therapy, the requested medication is medically appropriate. There is sufficient support for the requested medication in this clinical setting. Therefore, obinutuzumab (Gazyva) 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 medical oncology 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: Overturned

A 53-year-old female enrollee has requested for a CTA coronary artery for evaluation of her coronary disease.   Findings:  Two physician reviewers found that there are guidelines from the American College of Cardiology (ACC) regarding the appropriate use of CTA coronary artery. The use of this diagnostic procedure for strongly positive stress testing for patients with chest pain has an inappropriate recommendation per the ACC guidelines. The patient is at high risk for coronary artery disease given her recent myocardial infarction. Her cardiolite test suggests ischemia.  Normally, the guidelines would suggest traditional cardiac angiography as the next step, and CTA coronary artery as an intermediate step as inappropriate.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the patient has shown dramatic improvement since he enrolled in the school districts early intervention program. His combativeness has markedly decreased, his intelligence is normal, and his language is normal except for a mild delay in pragmatic speech. This improvement has been without ABA therapy and strongly suggests that the patient is not autistic. The medical literature indicates that there can be significant co-morbidity and overlap between ADHD and autism (Taurines, et al). All told, there is a lack of confirmatory evidence supporting a diagnosis of autism in this case. Current practice guidelines do not recommend ABA therapy for patients who do not have a confirmed diagnosis of autism. Based on the available scientific literature and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested Botox injections for the treatment of her post herpetic neuralgia. Findings:  The physician reviewer found that there are a variety of treatments for PHN.  As there is no documentation or evidence that the patient has tried gabapentin or pregabalin, both of which are standard non-opiate treatments for PHN, I cannot say that this patients PHN is refractory.  Botox may be beneficial in treating this patients PHN, and may be appropriate if her PHN becomes refractory, but there is no evidence that the patient has tried other standard therapies for PHN.  With the available records, and the limited amount of documentation of treatments actually tried and failed by the patient, Botox is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one hour one-on-one talk therapy sessions (psychotherapy), once monthly. In the medical literature, Nutt noted that psychotherapy is an integral part of patients treatment. The author reported that psychotherapy has been shown to be effective for acute depression and can help in preventing depressive relapse and recurrence. There is evidence that patients with chronic, complex mental illness improve with long-term psychodynamic psychotherapy, and a greater number of sessions is associated with better outcome. Similarly, the American Psychiatric Association (APA) states that to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. This patient has complex chronic depression and anxiety, for which regular psychotherapy is considered the standard of care. Given these findings, the requested one hour one-on-one talk therapy sessions (psychotherapy), once monthly, is medically necessary for treatment of this 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 reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female with a body mass index (BMI) of 60. She has multiple obesity related comorbidities. She has a long history of multiple failed diets. In addition, she has obtained psychiatric clearance for gastric bypass surgery. The Health Plan has denied authorization and coverage for gastric bypass surgery on the basis it is not medically necessary for treatment of the patients medical condition. With a BMI of 60 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested Enablex 7.5mg for the treatment of her bladder infection. Findings:  The physician reviewer found that the Health Plans requirement that the patient try the formulary alternative to Enablex prior to approval is reasonable and appropriate. The selective bladder anticholinergics which are prescribed for bladder overactivity are not specifically difficult to tolerate based on stomach issues. This is not a common or well-reported side effect. It is medically reasonable that the patient try the recommended alternatives. The Health Plan has provisions in place to substitute if the formulary drug is not tolerated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intravenous infusion and ceftriaxone sodium 250 mg per injection for treatment of the enrollee, who has a stated diagnosis of Lyme disease. Findings:  Three physician reviewers found that the medical evidence does not support the services at issue in this patients case. There is a lack of clinical or laboratory evidence that the patient has Lyme disease. The evidence-based guidelines for the treatment of Lyme disease refer to the use of two grams of ceftriaxone for a period of 28 days for any form of Lyme disease (e.g. late disease with central nervous system, cardiac and/or joint manifestations). The literature does not indicate that extending the period of therapy is of benefit. Additionally, there is a lack of evidence indicating that the dose ordered is effective. Final Result: The reviewers determined that the services at issue were 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: Reviewer 1 is board certified in internal medicine and is actively practicing. Reviewer 2 and 3 are board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer 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.