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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) indicate that all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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

An enrollee has requested reimbursement for the Testopel Pellets 75 mg provided, and prospective authorization and coverage for Testopel Pellets 75 mg (quantity 4 per year). Patients treated with testosterone require monitoring of serum levels and symptom management to assure the lowest effective dose is used to achieve treatment goals. However, based on the current medical literature, there is a paucity of data demonstrating that one formulation of testosterone supplementation is more effective than other preparations. Moreover, there is a lack of long-term studies that suggest a benefit with Testopel treatment over standard available therapies. Thus, the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Testopel Pellets 75 mg provided, and future Testopel Pellets 75 mg (quantity 4 per year), were not and are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks. This patient presents with near-continuous cluster migraine headaches that are refractory to her routine treatments and have substantially interfered with her ability to perform activities of daily living. Findings:  Three physician reviewers found that according to the most recent literature, sphenopalatine ganglion blocks have been shown to provide pain relief in patients with cluster headaches and migraine headache. While this technique is not considered first-line therapy for patients with migraines, it has adequate support in the scientific data as a safe and effective option for patients with refractory cluster or migraine headaches. This patient has become significantly disabled by her headaches despite aggressive medical management. Therefore, the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested sphenopalatine ganglion (SPG) nerve blocks/occipital nerve blocks are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certification in pediatric critical care and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intraoperative radiation therapy for treatment of her breast cancer. Findings:  Two physician reviewer found that there are many ways to deliver partial breast radiation, either as a sole modality or as a boost.  These radiation approaches of partial breast radiation include linear accelerator (LINAC) based, interstitial brachytherapy catheters, MammoSite balloon, intraoperative radiation therapy with a portable LINAC, and electronic brachytherapy.  Intraoperative radiotherapy with electron therapy was investigated in a study.  A total of 1,305 women were randomized to receive a single intraoperative radiotherapy fraction versus conventional whole breast radiation of 50 Gy in 25 fractions followed by a boost of 2 Gy in five fractions.  Intraoperative radiation therapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar.  A recent systematic review of intraoperative radiation therapy versus whole breast radiation also demonstrated a higher risk of ipsilateral breast tumor recurrence with intraoperative radiation therapy. The authors emphasized the need for prudent patient selection.  The medical evidence has not demonstrated that intraoperative radiation therapy is superior to standard approaches of delivering breast radiotherapy. 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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested for a positron emission tomography (PET) scan for evaluation of his gastric cancer.  Findings:  Two physician reviewers found that PET scanning is a functional scan that generally appears to be more sensitive in the evaluation of cancer than routine CT scans. It is becoming widely used in such situations. It is important to identify the objective parameters prior to chemotherapy so that one can evaluate the effectiveness of the treatment with the passage of time. Often a CT scan is sufficient for this purpose however in this case the CT scan did not demonstrate the metastatic disease, so a pre-treatment PET scan is very reasonable and likely to be of real benefit in this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female requesting a DEXA scan to screen for osteoporosis. Her providers progress notes of 9/17/04 indicate the patients mother and grandmother had osteoporosis. The patient indicates her grandmother, mother, and sister became aware of osteoporosis after breaking bones and losing height. The Health Plan indicates further information is required before a DEXA scan can be authorized.Screening for osteoporosis in post-menopausal women less than age 60 is recommended by most professional and regulatory authorities if there is at least one risk factor present. Based upon the information provided this patient has at least one risk factor present. Therefore, a screening DEXA scan is medically necessary for evaluation of this patient. As such, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested a partial hospitalization program stay at Puente de Vida for the treatment of her eating disorder and co-occurring depression and alcohol dependence. Findings:  The physician reviewer found that the patient had improved from the time of admission to the period in question. Her degree of impairment required therapy but was not such that it mandated treatment in a partial hospital program. Her functioning was not deteriorating. Her mood was slowly improving, and her weight was relatively stable. The significant neurological side effects are not clearly delineated by the psychiatrist in the psychiatric progress notes, and the need to manage this in a partial hospital program was not demonstrated. Further, the patients condition at the time in question did not require the structure, monitoring and medical psychological intervention as found in a partial hospital program. The patients treatment needs could have been met in a less restrictive form of treatment than a partial program during the period in question.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that Norco is not medically necessary for treatment of this patients medical condition. Short release/acting medication such as Norco is associated with a high risk of dependence and tolerance; therefore long-term administration is not recommended (Fishman, S.M.). Baron and McDonald reported that high dose and short acting 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. Further, short-acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Therefore, Norco as requested by the patient would be contradictory to providing safe and effective treatment and is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy for treatment of the enrollee, who has a history of enlarging uterine fibroids. Findings:  The physician reviewer found that the physician reviewer found The current medical evidence supports the requested services in this clinical setting. The patient is postmenopausal with symptomatic fibroids. A myomectomy is typically reserved for women who desire a fertility sparing procedure. The hormonal medications that are used in reproductive age women are generally not appropriate for postmenopausal women, and generally fibroids naturally decrease in size and symptoms after menopause.  Although the patient has a history of a thickened endometrium, there is no documentation of postmenopausal bleeding. Additionally, she had a negative endometrial biopsy. There is sufficient support for the requested hysterectomy in this patients case. Therefore, the requested hysterectomy is 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 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 patient is a 38-year-old female with a multiplicity of seemingly unrelated symptoms. Equivocal improvement in the patients non-specific symptoms has been noted with growth hormone therapy. Therefore, the patient wishes to continue to receive growth hormone therapy. The Health Plan has denied coverage for growth hormone therapy indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted literature citations are not pertinent to patients such as this patient. A low IGF-1 is not an adequate test for adult growth hormone deficiency. For example, obese people have low IGF-1. An increase in IGF-1 would be expected with growth hormone injections. In addition, the patients GH stimulation test was normal. Furthermore, the laboratory tests are inconsistent, e.g., a high TPO followed by a normal TPO. Thus, there is no evidence that growth hormone injections have resulted in improvement in the patients condition. There is no medical indication for continued growth hormone therapy.  Based upon the information set forth above, 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: Urgent Care
Decision: Upheld

A 49-year-old female enrollee has requested for an emergency room visit for treatment of her severe head pain. Findings:  The physician reviewer found that the symptoms did not present suddenly, as would a ruptured aneurysm or subarachnoid hemorrhage. She was not suffering any symptoms suggestive of meningitis, such as fever or neck stiffness. The patient had experienced a headache of this magnitude before. She required only oral pain relievers in the emergency department.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz. Xeljanz is U.S. Food and Drug Administration (FDA) approved for the treatment of ulcerative colitis. As noted in the medical literature, Xeljanz has a different mechanism of action than aminosalicylate immunomodulators, anti-TNF therapies, and Entyvio. Xeljanz has been demonstrated to be effective in a double-blind, placebo-controlled trial of patients with moderate-to-severe ulcerative colitis, with up to 78% clinical response and 41% clinical remission at eight weeks. The current medical literature supports Xeljanz as medically necessary for treatment of this patients ulcerative colitis. This patient has failed multiple standard therapies. Specifically, the patient did not improve with anti-tumor necrosis factor (TNF) agent Remicade or high-dose Entyvio. Thus, treatment with another anti-TNF agent, Humira, is likely to be ineffective. All told, Xeljanz is supported as medically necessary for the treatment of this patients ulcerative colitis.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 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: The enrollee has requested authorization and coverage for platelet rich plasma (PRP) for the knee. Currently, there is limited reliable clinical evidence to guide the use of PRP for treatment of knee pain. In addition, transient side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of recipients, compared to hyaluronan and placebo. Further, the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for treatment of osteoarthritis of the knee give an inconclusive recommendation for the use of PRP use in the treatment of knee arthritis, which means that there is a lack of compelling evidence that the treatment is safe and effective at long-term follow-up. Accordingly, PRP injections are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.One reviewer found that PRP injections are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Upheld

A 29-year-old male enrollee has requested physical therapy sessions for one hour, twice per week for treatment of his quadriplegia status post brain stem stroke. Findings:  The physician reviewer found that this patient had a brain stem stroke more than 10 years ago.  His neurological recovery is expected to have plateaued.  He is reported to have been making recent progress with gait training, but the records do not clearly demonstrate significant functional progress.  It is not clear that the recent ambulation gains that are reported are not essentially just a reversal of a regression that occurred over a period of about eight months prior to the change in therapy venue. In the submitted letter, it was reported that the patient needed minimal assistance 75% of the time, but the level of assistance needed the other 25% of the time was not documented. Overall, his ambulation levels have been fluctuating, but have been very modest.  It is not evident that his ambulation has been functional outside of the therapy setting.  Furthermore, it is not evident that his overall functional status outside of the therapy setting has been improving.  He has continued to require 24-hour caregiver supervision and/or assistance. There is no documentation of significant progression towards independence with respect to his primary means of mobility at home or in the community (e.g., using a manual or power wheelchair). In addition, it is not evident from the records that functional ambulation in the home or community would have been a realistic or safe recent functional goal.  There are no documented physician examinations in the records that clarify what his cognitive status, manual muscle testing levels, proprioception, cerebellar functioning or spasticity levels are.  He had been undergoing extensive physical therapy, including gait training, for a long period of time.  Despite this extensive therapy, however, he had not achieved functional ambulation.  The additional physical therapy in question, therefore, would not have been expected to have resulted in significant, sustained functional gains.  The therapy was maintenance in nature.  All told, physical therapy sessions performed were not medically indicated. Additionally, the medical necessity of continued physical therapy, one hour, twice per week, has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old male enrollee has requested reimbursement for neuropsychological testing performed on two dates for evaluation of the enrollees attention deficit/hyperactivity disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the testing at issue in this patients case.  This patient was diagnosed with attention deficit/hyperactivity disorder.  The current medical evidence supports neuropsychological testing in selected patients.  As noted by Pritchard and colleagues, neuropsychological testing can provide information that can potentially reduce risks for poor outcomes and improve the quality of life for children with attention deficit/hyperactivity disorder.  However, in this patients case, there is no indication that the patient underwent initial evaluation by his pediatrician using preliminary screening tests which would have suggested the possibility of attention deficit/hyperactivity disorder.  In this clinical setting, given the absence of a preliminary evaluation by a medical or psychological care provider, the medical necessity of the testing at issue cannot be established.  All told, neuropsychological testing performed was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for 100 days of residential treatment for behavioral health at the Centre for Neuro Skills. Findings:  The physician reviewer found that the records do not contain evidence that the patient would likely permanently improve due to treatment. The records indicate that the patient has a pathologic dysfunction of his frontal and temporal lobes. The records demonstrate that the patient temporarily improves with structure, but the results are not sustained. There is a lack of evidence to support that additional treatment would alter the patients outcome. 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 physician 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.