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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for the treatment of his medical condition.   Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The medical records note short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), which is a rare condition.  There is a lack of standardized or proven therapies for SUNCT.  Treatment for this condition is off-label.  OnabotulinumtoxinA is indicated for prevention of chronic migraine, and has decades of safety data available. It is believed to exert its therapeutic effect by inhibition of pre-synaptic neurotransmitter release.  This patient has been diagnosed with SUNCT and has failed therapy with previous medications. He has had marked relief with Botox, and therapeutic response has been confirmed by pain recurrence upon wear off.   All told, the requested Botox injections are medically indicated 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old male enrollee has requested a narrow band UVB home phototherapy unit for treatment of his vitiligo. Findings:  Three physician reviewers found the NBUVB home phototherapy unit was likely to be more effective for this patient than other available options. Treatment for vitiligo is difficult and prolonged and treatment with NBUVB by a home therapy unit provides an established modality for treatment of vitiligo. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to available therapies. The clinical aspects of each individual patients vitiligo should be considered including the treatments tried and failed as well as published results of clinical research trials of NBUVB in vitiligo. In this case, the patient previously had effective treatment with NBUVB therapy with repigmentation of skin lesions. Therefore, the services at issue were likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient treatment for treatment of her anorexia nervosa and obsessive compulsive disorder. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was engaged in active treatment that included psychiatric and nutritional services, family interventions, and both individual and group therapies.  Additional factors consistent with parameters established by the American Psychiatric Association that warranted ongoing intensive outpatient program care included the need for structure to help with weight management and dietary habits, and her significant psychiatric comorbidity of excoriation disorder and obsessive compulsive disorder.  Further, the step-down transitioning from partial hospital to intensive outpatient program, prior to outpatient services, is a well-accepted clinical progression in community practice.  Per the medical records, the patient remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of intensive outpatient program treatment.  All told, the services at issue were medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services provided and  forward.  Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  The progress notes indicate the patient has made improvements behaviorally. However, he continues to have aggression.  It appears that he is receiving evidence-based treatment for the management of his behavioral health conditions.  The records indicate that the patient continues to need this level of care in order to manage his poor social skills, impulsivity, and aggression. The current medical evidence supports intensive outpatient program services in this patients case.  Per the clinical notes, the patient has not stabilized, and his current behavioral issues are only minimally improved.  All told, intensive outpatient program services provided forward 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for genetic testing. The Health Plan has denied the testing at issue as investigational. The patient has a medical history that includes seizures that began with myoclonic, absence and tonic clonic types of seizures. The absence seizures began with staring spells and progressed to include myoclonic movements. He has had increased frequency of convulsions in the past months, which occur up to weekly. These have been complicated by multiple shoulder dislocations. On a chance this condition may be related to an immune-system disorder, he was administered intravenous immunoglobulin (IVIG). The patient responded with less fatigue and the convulsions stopped for at least five months.Three physician reviewers found that in this case, the patients seizures have worsened in both frequency and severity despite medical management. Traditional diagnostic modalities have not yielded a specific diagnosis or suggested long-term successful therapy. Updated bioinformatics analyses make a genetic diagnosis via exome sequencing feasible. Further, a specific diagnosis may lead to more targeted and beneficial therapy. Based upon the model coverage policy from the AAN and available literature, genetic testing performed was likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in genetics 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 female enrollee requested vaginal birth for medical treatment of her breech presentation.  Findings:  The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) committee opinion in regards to the mode of term singleton breech delivery issues the following recommendations: Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented.  Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient's informed consent should be documented. In this case, the patient has been counseled regarding the risks of vaginal breech birth and the risks of cesarean section. The patient has indicated that a non-Plan provider and facility has experience with vaginal breech deliveries and is willing to offer this option to her.  Based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male has requested the medication Zylet for treatment of teary eyes.    Findings:  The physician reviewer found that there is no evidence in the record of trials of other antibiotic/steroid combination medications. There is no specific infection being treated that requires Tobramycin. Nor is there any reason identified for choosing one type of steroid over another. There are other antibiotic-steroid combination medications available. As such, the medical necessity of Zylet has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin Flexpro and/or Nutropin AQ Nuspin. This patient has idiopathic short stature, defined as height less than 2.25 standard deviations (SDs) below the norm for age and gender, without the presence of GH deficiency. The U.S. Food and Drug Administration (FDA) has approved growth hormone (GH) therapy for patients with idiopathic short stature. This patient had poor growth velocity prior to receiving GH, which is consistent with abnormal growth. The patients growth velocity improved after a GH trial, which suggests he will benefit from further treatment with GH therapy. This patient has a mid-parental target height of 170 cm, which is significantly above his extreme short stature, indicating he will not reach his genetic potential without GH therapy. The records document that his estimated adult height is 158 cm, which is significantly below his mid-parental target height of 170 cm. Given these findings, both of the requested agents, Norditropin Flexpro and Nutropin AQ Nuspin, are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 pediatrics with subspecialty certification in pediatric endocrinology 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 and authorization and coverage for Intermittent Theta Burst Stimulation/Transcranial Magnetic Stimulation, 2 times per week, 5 sessions per day.Transcranial Magnetic Stimulation (TMS) therapy is currently approved for treating patients who are suffering from the acute phase of major depressive disorder (MDD). TMS is not currently approved for the treatment of bipolar disorder, based on consensus statements and lack of clinical trials demonstrating efficacy. While there have been some small studies to explore the use of TMS in bipolar disorder, they have not shown statistically significant remission rates. There are also ongoing studies investigating the use of TMS for the depressed phase of bipolar affective disorder (BPAD), but they have not yet demonstrated evidence that would support the use of TMS for bipolar disorder. In this case, the patient has been diagnosed with bipolar 2 disorder and anxiety. Despite the fact that the patient reports subjective improvement, the patient does not have a diagnosis of major depressive disorder, for which TMS is currently approved. TMS is also not currently approved for the treatment of bipolar disorder, the patients diagnosis. Under these circumstances, Intermittent Theta Burst Stimulation/Transcranial Magnetic Stimulation, 2 times per week, 5 sessions per day, was not, and is not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat 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: An enrollee has requested reimbursement for Orthovisc injection series in both knees provided on 2/17/21, 2/24/21, and 3/03/21 and prospective authorization and coverage for Orthovisc injection series in both knees in six months.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of lasting benefit from prior injections. Furthermore, the options are limited. The patient has tried other conservative treatments, with the option being surgery. Therefore, the Orthovisc injection series provided into both knees on 2/17/21, 2/24/21, and 3/03/21 was medically necessary for the treatment of this patient. Additionally, the requested Orthovisc injection series into both knees in six months is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested Qualaquin for treatment of her polyneuropathy. Findings:  The physician reviewer found that this patient has a familial sensorimotor polyneuropathy, and this is commonly associated with muscle cramping. This patient has used Qualaquin for her cramping with good results for many years. Qualaquin is effective for the treatment of cramping in some patients. She had good control of cramping with Qualaquin, and discontinuation of the medication resulted in an increase in symptoms. This patient has tried multiple alternative therapies, but none have been as effective as Qualaquin. Thus, Qualaquin is medically indicated for the treatment of this patients neuropathy-induced cramping.
Appeal type: Experimental/Investigational
Decision: Overturned

A 25-year-old male enrollee requested  Genotropin growth hormone (GH) therapy for medical treatment of his adult GH deficiency.   Findings:  Two physician reviewers found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, in patients who have previous history of head trauma and who have documented low IGF-1 levels, GH therapy is indicated if stimulation testing with glucagon is performed and peak GH levels are documented to be less than 3.0. This patient has a prior history of head trauma, low documented IGF-1 level, and a peak GH level of 2.1 after stimulation with glucagon. For these reasons, the requested Genotropin GH therapy is likely to provide this patient with an improved health outcome when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. According to the American Academy of Child and Adolescent Psychiatry (AACAP), children and adolescents should be treated in the least restrictive setting possible and to maintain and foster natural supports. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS) to determine the most appropriate treatment setting, the IOP services provided were not and are not medically necessary. This patient presented with no risk of harm due to a lack of current self-harm ideation (score 1). The patient demonstrated mild functional issues given their difficultly with family relationships (score 1). The patient presented with no active serious medical problems or substance use issues (score 1). The patients recovery environment is mildly stressful, as the patient has issues with family relationships, but has a stable housing situation (score 2). The patients recovery environment is highly supportive as their parents are actively involved in treatment and attend family therapy sessions on a regular basis (score 1). The patient has demonstrated limited improvement in limited prior treatment, but their behaviors have improved during IOP sessions (score 3). The patient has been both constructive and obstructive toward treatment, as they participate in therapy, but do not demonstrate motivation to improve (score 3). The patients parents have been constructive and have worked actively with the patients providers (score 2). This gives the patients presentation a composite score of 14, which correlates with outpatient services. Moreover, the recommendations for treatment of intermittent explosive disorder include pharmacotherapy plus cognitive behavioral therapy (CBT), which can be provided on an outpatient basis. All told, the IOP services provided were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C.  Three physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not document discontinuation of alcohol use.  There is a lack of support for treatment with antiviral agents in the setting of continued alcohol use. Alcohol and hepatitis C virus appear to act synergistically in promoting progression to cirrhosis and increasing the risk of hepatocellular carcinoma.  Additionally, available data suggests that ongoing alcohol consumption significantly impairs the efficacy of therapy for hepatitis C virus elimination. All told, the requested medication Harvoni is not medically necessary for the treatment of this patient.  Final Result: Three reviewers 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.