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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that There is no documentation of emergency room visits or acute inpatient hospitalization between the patients discharge from the wilderness therapy program and admission to residential facility. The provided documentation for admission to the RTC did not contain reports of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living. There was no documentation of persistent mood instability.  Although the patient intermittently documented to be isolative and anxious there was no indication that this severely affected the patients functioning.   The American Society of Addiction Medication Criteria (ASAM) is a set of objective guidelines used to assist with treatment planning, and advocates for service intensity provided in the least intensive but safe treatment setting. In this case, there is no documentation of active withdrawal symptoms, unstable vital signs, dangerous or non-supportive recovery environment, or failure of treatment at lower level of care immediately preceding the residential admission that would support treatment at RTC level of care. Research supports the use of short-term residential treatment after acute inpatient hospitalization for stabilization of patients with serious mental illness. Patients with admissions less than 28 days are no more likely to have a readmission, leave abruptly, or not follow through with services as patients who have longer stays. In this case, the patient had no documentation of admission to an acute inpatient hospitalization prior to residential care. There is also no documentation of failed treatment at the intensive outpatient or partial hospital level of care prior to residential care. Based on the clinical documentation provided and current medical literature the RTC level of care services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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 60-year-old female enrollee requested a neurosurgery consultation for medical treatment of her constant low back pain radiating to the right leg associated with numbness and tingling in the right leg. Findings:  The physician reviewer found that based on the available medical records, the requested neurosurgery consultation is medically necessary for treatment of this patients medical condition. The records indicate she has symptoms including low back pain radiating to the right leg associated with numbness and tingling in the right leg. The patient also has a positive Lasegue on the right to 10 degrees and decreased pinprick and light touch on the right L5-S1 dermatome. Given these findings, the patient should undergo an evaluation by a neurological surgeon as requested.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested prolotherapy for the treatment of her knee pain. Findings:  Three physician reviewers found that prolotherapy is a sugar-based solution that is injected for treatment of a variety of pain disorders. Its mechanism of action is unclear, as basic science studies are limited. It is generally considered an investigational/experimental management due to insufficient peer-reviewed literature, particularly, insufficient randomized controlled trials reporting on its safety and efficacy. Prolotherapy is not a generally accepted medical procedure/intervention and is not readily utilized in the standard of care management of osteoarthritis of the knee.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for 24 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1b. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), this patient should be considered high priority for therapy due to cirrhosis. However, the only recommended therapy for patients with cirrhosis who have failed a regimen of Sovaldi and ribavirin is Harvoni and ribavirin for 24 weeks. This recommendation is based on studies showing high cure rates approaching 100% after failure of Sovaldi and ribavirin for 24 weeks, even in patients with cirrhosis. There is a lack of current peer-reviewed published evidence to support the use of Viekira Pak in a patient who has failed therapy with Sovaldi and ribavirin. Based on these guidelines, the requested Viekira Pak for 24 weeks is not medically necessary for treatment of this patients chronic hepatitis C virus infection. 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: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health guidelines for weight loss surgery. She reports that she has tried diet and exercise plans. The Health Plan contends that the patient should have attended a medically managed weight loss program for at least six months within the last three years prior to pursuing weight loss surgery. However, there are no studies that show that patients who attempt such programs have different outcomes than those who do not undergo such attempts. In fact, studies indicate that the drop out rate increases for patients who are denied surgery. This patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity. With a BMI of 51, weight loss surgery is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested bilateral thigh skin excision for the treatment of her excess skin. Findings:  The physician reviewer found that due to the absence of any office notes documenting infections, the patients history of uncontrollable and recurrent intertrigo cannot be verified. Either the patients rashes have not been severe enough to require medical treatment or the appropriate treatment notes have not been submitted. The patients condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care. Surgical dermatolipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested Hyalgan/Supartz injection for treatment of the temporomandibular joint (TMJ) disorder.  Findings:  Two physician reviewers found that there is a lack of controlled studies supporting the efficacy and safety of the use of hyaluronic acid injection for the treatment of TMJ. Furthermore, the patient received injections without any objective documentation of efficacy, pain reduction or functional improvement. Therefore, the request for an additional injection is not clinically indicated. Based on the medical literature cited above, the request for Hyalgan/Supartz injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg tablets for 12 weeks 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus genotype 1. As per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. In addition, the requested medication is expected to potentially cure hepatitis C infection and prevent further damage of the liver and progression of the disease process and development of cirrhosis long-term and its potential complications. Therefore, it is medically necessary for this patient to be treated with Harvoni for eight weeks to prevent further development and progression of fibrosis due to ongoing hepatitis C infection and prevent potential complications of advanced liver disease, long-term. Final Result: Three reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are 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: An enrollee has requested authorization and coverage for Odefsey 200-25-25 mg tablets for treatment of the enrollees human immunodeficiency virus (HIV). Findings: The physician reviewer found that Atripla contains tenofovir disoproxil which has been associated with statistically significant reduction in renal function in several studies. Tenofovir alafenamide, contained in Odefsey, has been shown to be as effective but with a lower risk of kidney toxicity and bone density changes when compared to tenofovir disoproxil. 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 infectious diseases 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 bilateral platelet-rich-plasma (PRP) injections in both elbows for treatment of the enrollees epicondylitis. Findings:  Two physician reviewers found that the patient has been diagnosed with epicondylitis. The medical records document the use of tennis elbow bands, prior cortisone injections, wrist brace and a 24-month duration of symptoms. Clinical notes document comorbidities of acute coronary syndrome, diabetes mellitus type 2, headache, diabetic retinopathy, gastroesophageal reflux disease, coronary artery disease and hypertension. The patient reported pain with resisted wrist extension and pain at lateral epicondyles. The patient reported continued symptoms after conservative therapy. The provider discussed surgery as a treatment option. The patient requested coverage for bilateral platelet-rich-plasma (PRP) in both elbows for treatment of epicondylitis. The Health Plan denied the requested services as investigational for treatment of this patient. While there have been studies comparing PRP injections to other treatment options, there is a lack of high quality evidence showing the superior efficacy of PRP for treatment of epicondylitis. Further high level studies are needed to define the efficacy of PRP.  In one study, a double blind placebo controlled randomized trial was performed with evaluation at six months utilizing a visual analog scale scoring technique. Twenty-five patients were randomly assigned to each group. The study found that two ultrasound guided PRP injections for epicondylitis were not more efficacious than saline injections at six month follow-up. In another study, the researchers reported on a systematic review of the literature as to the efficacy of PRP injections for chronic lateral epicondylar tendinopathy. Six studies were reviewed, four considered of high quality and two low quality studies. The researchers concluded that based upon the best evidence synthesis, there was strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy. In sum, based upon the medical literature, bilateral platelet-rich-plasma in both elbows are not likely to be superior to alternative therapies for treatment of this patient. Final Result: The 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: All three physician reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Otezla for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Recently released guidelines for the treatment of psoriatic arthritis note that conventional synthetic disease modifying antirheumatic drugs are recommended as initial therapy after failure of nonsteroidal anti-inflammatory drugs.  Then, if necessary, biological disease-modifying antirheumatic drugs or a targeted synthetic disease-modifying antirheumatic drug may be appropriate.  In this case, the patient has a medical history which is not currently contraindicated for the treatment with anti-tumor necrosis factor agents or other biological agents.  As such, the request for Otezla 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 internal medicine with sub-specialty certification in rheumatology 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 Botox treatment for his jaw pain. Findings:  Three physician reviewers found that Botox therapy is not approved by the U.S. Food and Drug Administration (FDA) for treatment of TMJ disorders. There is a lack of consensus in the peer-reviewed literature regarding the efficacy of Botox for the treatment of TMJ disorders due to limited studies and conflicting results. There is some literature that indicates that use of Botox in the treatment of TMJ disorders may cause decreased bone density of the condyles, indicating that this treatment may be harmful. Final Result: The reviewers determined that the service at issue was 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, 2, and 3 are board certified in dentistry 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with gender dysphoria. The patients therapist reported the patient socially transitioned to male in January 2018 and began hormone treatment in August 2018. The provider noted the patient would benefit in his transition process by having gender-affirmative surgery. The patients plastic surgeon noted the patient is an excellent candidate for a transgender mastectomy. It was noted the patient experiences chest dysphoria and binds his chest daily. The patients parent has requested authorization and coverage for chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction). The Health Plan denied the request and reported the requested surgery is not medically necessary for the treatment of this patient. At issue in this case is whether chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction) is medically necessary for the treatment of the patients medical condition. Coleman and colleagues reported, Chest surgery in female to male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. Researchers reported, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient was noted to experience chest dysphoria and binds his chest daily. He socially transitioned to male in January 2018 and began hormone treatment in August 2018. The patients providers have noted he is an excellent candidate for transgender mastectomy. The medical evidence supports the requested surgery in this clinical setting. Therefore, chest reconstruction (CPT 19303 - simple complete mastectomy, 19350-50 or 15200-50 - nipple reconstruction) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 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.