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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for benzphetamine tablets for treatment of the enrollees fatigue. Findings: The physician reviewer found that benzphetamine is approved for management of exogenous obesity as a short-term adjunct (a few weeks) in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.  In this case, the patient is not using this medication for an FDA approved indication.  His diagnosis includes chronic fatigue syndrome, which is a complicated disease characterized by unexplained, persistent and relapsing fatigue.  The only treatment that has been shown to be effective in treating chronic fatigue syndrome is cognitive behavioral therapy (CBT) and graded exercise therapy. The documentation does not support that the patient has tried and failed non-pharmacologic approaches to chronic fatigue syndrome. For the treatment of ADD, medication with stimulants including dexmethylphenidate, methylphenidate and dextroamphetamine in addition to CBT are considered first-line treatment.  The use of benzphetamine is not supported in this case.  The documentation does not support that he has failed treatment with CBT.  Furthermore, benzphetamine, although a stimulant, is not recommended for treatment of ADD. All told, benzphetamine is not medically necessary for the treatment of this patient. 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 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

A 55-year-old female enrollee has requested for azithromycin 250mg, #30 for treatment of her Lyme disease. Findings:  The physician reviewer found that there is a lack of evidence supporting either recurrent pneumonias or Lyme disease.  Moreover, azithromycin would not be the drug of choice in either situation. In addition, the suggested dosing would be excessive. The Infectious Diseases Society of America recommendations for treatment of Lyme disease note that macrolides (the family that includes azithromycin) are not recommended as first-line therapy for treatment of early Lyme disease.  A search of the National Library of Medicine database does not reveal articles that support the use of this drug in Lyme disease. Similarly, there is little data about the use of this drug for chronic pneumonias.  Finally, this antibiotic has a very long half-life that allows five days dosing to yield therapeutic serum levels for approximately two weeks.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet and morphine pain medications. Findings:  The physician reviewer found that there is a lack of support for the requested medications in this clinical setting.  Per the documentation available for review, not all non-opioid treatment options have been utilized. The records do not indicate that behavior therapy has been documented or performed for this patient despite much research to support its use. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. The medical evidence shows that continuation of pain medications should be under the direct guidance of a mental health professional. In this patients case, there is documentation of a history of getting early refills, not being forthcoming with the opioids she was taking, and misrepresenting what she was doing with the medications. Moreover, a treatment option of non-opioid therapy was offered to this patient, but she declined. The medical literature recommends the consideration of alternatives to opioid medication therapies. It is not unreasonable to wean the patient to a lower dose of opioids or even off opioids. Also, the documentation indicates evidence that this patient has developed a tolerance to her medications since the start of the narcotics. As per medical evidence, dose escalation is not a long term plan but a short term plan for treatment of tolerance. Finally, continuation of opioid prescribing at higher doses without proper treatment for the opioid use, sets the patient up for higher morbidity and mortality. There is sufficient support to offer interventional treatments for this patient's pain. For all these reasons, Percocet and morphine pain medications are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty 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

The enrollee is requesting authorization and coverage for biofeedback training, perineal muscles, anorectal or urethral sphincter. The enrollee has chronic constipation, overflow fecal incontinence, and pelvic floor muscle coordination problems. A colonoscopy was normal, and there is no known family history of colon cancer. A pelvic ultrasound was normal. During an office visit, records show the enrollees symptoms have persisted for a long period of time, but have worsened in the past few months. He also reports some urinary incontinence. The physician documented the enrollee would benefit from biofeedback therapy for retraining of his pelvic floor muscles. The enrollee reports he has difficulty controlling his bowel movements long enough to make it to a toilet. The enrollees physician reports this is the only available treatment for this functional disorder. A systematic review of 21 studies (with a total of 1525 enrollees) on the use of biofeedback for fecal incontinence concluded that biofeedback and electrical stimulation may offer an advantage over electrical stimulation alone or exercises alone, but larger, well-designed trials are needed before definitive conclusions can be made. Literature reports a specialty society guideline recommends biofeedback therapy as a first-line treatment for symptomatic constipation due to pelvic floor muscle coordination problems; however, this was based on a single randomized controlled trial with 77 enrollees.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in general 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days). Motegrity is a medication that is U.S. Food and Drug Administration (FDA) approved for the treatment of motility in the gastrointestinal tract in patients 18 years of age and older. In an open-label pilot study, Motegrity demonstrated a favorable effect on stool frequency, stool consistency, and fecal incontinence frequency in children with functional constipation (Winter, et al.). However, in a multicenter randomized controlled clinical trial including 213 children with functional constipation, Motegrity was found to be less effective in increasing stool frequency and decreasing fecal incontinence frequency when compared to placebo (Mugie, et al.). Overall, there is a lack of data demonstrating the safety and efficacy of Motegrity in the pediatric patient population. Thus, Motegrity is not expected to decrease this patients likelihood of having obstructive symptoms. All told, the requested Motegrity (2 mg tablets, 30 tablets per 30 days) is not medically necessary for treatment of this patient. 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 pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested mental health intensive outpatient services for treatment of his obsessive compulsive disorder.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The records document a debilitating anxiety disorder that impairs multiple domains of functionality.  In accordance with modern psychiatric practice, the patient had first pursued treatment in the outpatient setting.  He failed that level of care and was referred to an intensive outpatient program.  Based on the documentation provided, this patient had neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  Subsequent psychiatric evaluation noted passive suicidal ideation along with an anxious and sad presentation in context of severe and disabling obsessive compulsive disorder.  In addition to the obsessive compulsive disorder, the patient was diagnosed with posttraumatic stress disorder and major depressive disorder.  The evidence-based services have been for active treatment and are being delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  Based upon current practice guidelines and relevant peer-reviewed literature, mental health intensive outpatient services were and are medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were and 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay by moving from program-driven to clinically driven and outcomes-driven treatment. In this case, on admission, the patient was not in withdrawals and not at imminent risk for withdrawals. She was in the process of tapering from OxyContin and Klonopin. She was not a danger to herself or others, and she showed no self-harming behavior. There was no evidence of emotional, behavioral, cognitive, or impulsive factors requiring residential level of care for containment. The patient had a history of at least six prior residential treatments, and reported a 10-year period of sobriety, demonstrating the ability to remain sober independently. Psychiatrically, the patient did not require the containment of a 24-hour/seven day per week environment with 24-hour/seven day per week medical and nursing monitoring. The records did not document monitoring of her weight, and there was no clear detailed description of her eating disorder behaviors beyond the fact that they were intermittent. There was no indication that there were any 12-step groups provided, or any other type of therapeutic intervention beyond the limited therapists notes. There was no description of any relapse prevention plan. There was nothing to suggest that she could not have been treated in an ambulatory setting, as evidenced by the fact that she was already on a taper for both the Klonopin and the Oxycontin. Therefore, residential treatment center services provided were not medically necessary for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary:A female enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees back pain. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Also acupuncture is superior to conventional massage, dry needling of local myofascial trigger points, and sham laser acupuncture, for improving active range of motion and pain in patients with chronic neck pain. In this case, the patient is significantly symptomatic despite treatment with physical therapy and oral medication. Based on the documentation submitted for review, acupuncture services are supported as 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 reviewer is board certified in oriental 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 patient presented to her primary care provider. The records noted a growing skin lesion on the upper left back. This lesion had been present for approximately one year, has gradually increased in size, and has been bleeding intermittently. The provider noted that the patient is fair skinned with multiple freckles. There was no personal history of skin cancer noted. The records noted basal cell carcinoma. The treatment plan included the performance of Mohs micrographic surgery to the left scapular back. The patient has requested authorization and coverage for Mohs micrographic surgery. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested services. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. Small, well-circumscribed or superficial tumors may be treated with cryotherapy, photodynamic therapy, or topical anti-tumor medication. In selected patients, radiation, including external beam radiation or brachytherapy, is an appropriate and effective option. In this case, based on the truncal location, nodular (rather infiltrative) type of basal cell carcinoma, and its size smaller than one centimeter, the requested Mohs micrographic surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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 authorization and coverage for Harvoni 90-400 mg for eight weeks for the treatment of this patients hepatitis C infection. 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 applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg for eight 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acute rehabilitation facility services upon discharge. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a recent history of meningitis and stroke.The submitted documentation does not support the medical necessity for the requested services in this patients case. The patient has sustained multiple neurological insults, including a cerebral stroke, cerebral meningitis and a cervical spinal cord injury due to abscess. The cervical spinal cord injury has caused left greater than right arm weakness. The cerebral insults have caused cognitive impairments and may have contributed to his weakness. The abscess and osteomyelitis in the cervical spine were surgically addressed, which is critical in the management of this condition. The patient is noted to have residual functional impairments. The patients health and functional status are not noted and notably, there are no indications that this patient is currently medically stable. There are, moreover, no updated physical or occupational therapy evaluations since his surgery in the documentation provided. The only therapy notes provided indicated that he was lethargic at the time.  He was also being physically restrained for his safety at the time. Current standard of care for admission to acute inpatient rehabilitation requires documentation to support that this level of care is medically necessary.  In light of the lack of relevant recent clinical documentation, both with respect to the medical and therapy disciplines, the medical necessity of acute inpatient rehabilitation has not been established at this time.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 physical medicine and rehabilitation 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 has requested authorization and coverage for Spinraza. Spinraza is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of SMA, which is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons and poses significant adverse outcome in affected population. Survival motor neuron 1 (SMN1) and protein encoded by SMN1 is critical for survival and functioning of motor neurons. An almost identical gene SMN2 produces a truncated protein (SMN2). The number of copies of SMN2 genes determines the severity of disease, with a greater number of copies associated with less severe disease. Spinraza was demonstrated to be safe and effective in the treatment of patients with SMA in a sham controlled phase 3 clinical study. The authors reported that the study was stopped early based on significantly favorable results in interim analysis and all the patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study. Given this support, the requested Spinraza is medically necessary for 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.