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

The parent of an eight-year-old female enrollee has requested continued partial hospitalization program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on medical documentation and case review, the patient was a candidate for transferring from PHP to a lower level of intensive outpatient program (IOP) services. This finding is also consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria from the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP). Additionally, Bertrand and colleagues overview of five innovative interventions for children with FAS discussed a wide range of possible treatments for children with cognitive, behavioral, or social problems resulting from prenatal alcohol exposure. The authors concluded that the individualized and targeted interventions specific to deficits among children with FAS can be implemented within a framework of community services typically available. For these reasons, the medical necessity of the requested PHP services has not been established in the care of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested proton beam radiation therapy for treatment of his right tongue base squamous cell carcinoma.  Findings:  Three physician reviewers found that proton therapy is a promising and emerging modality of radiation therapy for patients with head and neck cancers. The physical advantages inherent to protons, with rapid dose fall off, can yield improvements in the ability to escalate radiation dose or spare organs at risk. However, emerging clinical data suggest that further study should be conducted with proton beam radiation therapy compared to a similar cohort of patients treated with IMRT. All told, the requested proton beam radiation therapy is not likely to provide this patient with an improved health outcome when compared to standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old male enrollee has requested intra-stromal corneal ring implant surgery (INTACS) for the treatment of his keratoconus. Findings:  Three physician reviewers found that the INTACS surgery performed in this case was the most appropriate option for this patients clinical problems. He met all of the criteria for the INTACS procedure and reports good results following the surgery. The key point in this case is that the patient was found to have very dry eyes. Even in patients with dry eyes that are treated, corneal epithelial defects can occur which promotes inflammation. Inflammation in a patient with a corneal transplant can in turn lead to significant intraocular complications. In addition, when surgery is performed on a patient with dry eyes, there is always a possibility of a corneal melt. This is a very severe complication that can sometimes result in loss of the eye.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested Hyalgan injections for treatment of her left knee status post left knee arthroscopy.  Findings:  The physician reviewer found that although some questions remain as to efficacy, viscosupplementation is an accepted treatment for symptomatic osteoarthritis of the knee. Brzusek and Petron recommend viscosupplementation as a part of a comprehensive treatment strategy. In this case, however there is a lack of documentation of treatment other than the steroid injections. There is no documentation of treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or other medications, nor is there any discussion of the utilization of physical therapy for the patients knee complaints. Further, there is no discussion of the presence of any contra-indication to the use of NSAIDs or other medications. In the absence of such documentation, the medical necessity of the requested injections with Hyalgan has not been demonstrated in the records provided for review.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulation (Inspire upper airway stimulation system). In this case, the records provided for review document that this patient has obstructive sleep apnea (OSA). A drug-induced sleep endoscopy (DISE) reported no concentric collapse at velum and primarily anterior posterior collapse. The records noted that the patient had been unable to tolerate continuous positive airway pressure (CPAP) therapy. The provider recommended treatment with hypoglossal nerve stimulation. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA . Given these findings, the patient is a candidate for the Inspire device, given his intolerance to CPAP and anterior posterior collapse. Therefore, hypoglossal nerve stimulation (Inspire upper airway stimulation system) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested hypoglossal nerve stimulation (Inspire upper airway stimulation system) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in otolaryngology with sub-specialty certification in sleep medicine 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

The parent of a one-year-old male enrollee has requested physical therapy and occupational therapy for the treatment of the enrollees developmental delay. Findings:  The physician reviewer found that this patient has a number of dysmorphic features consistent with Goldenhar syndrome, but the CGH array did not demonstrate the typical chromosomal abnormalities. In addition, he demonstrates hypotonia, with delayed acquisition of fine and gross motor skills.  He has been receiving physical therapy services, with documented improvement. The patient has not yet undergone occupational therapy evaluation. Children with genetic disorders such as this patient frequently have hypotonia, delays in fine and gross motor skill development, sensory processing problems and oral-motor difficulties. Continued physical therapy is medically indicated for this patient to facilitate skill acquisition and to optimize functional development and mobility. With its focus on fine motor skill acquisition, processing of sensory information, and motor planning, occupational therapy, starting with a comprehensive evaluation, is also appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested morphine for treatment of her chronic pain.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. This patient has reported divergence by self-injecting morphine. It is noted that the patient violated her pain contract. The patients morphine was prescribed as a tablet and her provider indicated that morphine as an injectable was not an appropriate manner of taking the medication. The patient recently had an abscess to her right shoulder due to her injection techniques. Given the patients divergence from her pain medicine contract, the Health Plans recommendation that she follow-up with the Chronic Pain Department and the Chemical Dependency Recovery Program for a treatment plan that includes non-opiate medications and modalities is medically reasonable and appropriate. As such, the requested morphine is not considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation therapy for treatment of his medical condition. Findings: The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  In this patients case, anxiety dominates the patients phenotypic expression of distress, but an anxious-depression is present as well.  Despite the diagnosis of other depressive episodes, the records indicate that the patient meets criteria for a major depressive episode and thus the diagnosis of major depressive disorder.  The patients mood is lethargic, with a constricted affect.  His appetite is mood dependent.  The patient has poor energy, guilt, fatigue, sleep disturbance and negative thoughts and self-defeating schemas.  Further, the patient has tried many antidepressant medications and pursued psychotherapy.  Transcranial magnetic stimulation would be reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, the requested transcranial magnetic stimulation therapy 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a twenty-two month-old female with acute myeloid leukemia are requesting authorization for bone marrow transplantation with T-cell depletion and without total body irradiation.Reviewers Findings:  The reviewing physician found that the requested therapy is medically necessary for the patients condition.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary: This is a patient with wide spread chronic pain and Ehlers Danlos Syndrome (EDS). A progress on 3/24/20 from her Pain Management physician reports that with a decrease in Percocet and increase in Methadone dose, her joint pain has decreased to 4/10. At issue is whether the Methadone HCL 5mg tablets (180 tablets/30 day supply), and Methadone HCL 5mg tablets (180 tablets/30 day supply), purchased on March 27, 2020, April 24, 2020 and May 22, 2020, is and was medically necessary to treat the enrollees medical condition. Literature reviewed states that opiates may be used for pain. However, the authors report that there may be significant medical problems with long term use specific to EDS with gastrointestinal issues (such as constipation and nausea), and an increase in the symptoms of mast cell activation syndrome (such as an allergic reaction, bleeding, unstable blood pressure, and multi-organ issues).  Other literature reported that patients with EDS reported that the most helpful methods for managing their pain are opioids, surgical interventions, splints or braces, and heat therapy. The patients medical record reports success with a reduction in her joint pain level with the use of Methadone without any untoward medical issues.  Final Result: The reviewer determined that the requested service was and is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology        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: Overturned

The father of a 16-year-old female enrollee requested authorization and coverage of a custom knee brace. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollee status post anterior cruciate ligament repair.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested removal of breast implants and a mastopexy for the treatment of her pain. Findings: The physician reviewer found that the implant removals and capsulectomies performed were cosmetic. The patient had a periprosthetic capsular contracture, which is a known complication of breast implants. There is no evidence of an abnormal structure caused by congenital defect, developmental abnormality, trauma, infection, tumor or disease. Thus, the procedures at issue did not constitute reconstructive surgery. Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated. The American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation conclude that the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, and interference with the diagnosis or treatment of breast cancer. Based upon the evidence provided, the patient does not meet these criteria. Nor do the records document problems with activities of daily living or a need for narcotic analgesics. As such, the medical necessity of these procedures has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for assistance with the enrollees ambulation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablets. This patient presents with a history of alopecia areata that has been present for many years and is worsening. His area of involvement has been as severe as alopecia totalis, which affects the scalp, eyebrows, and eyelashes. The provider reports that the patient has been treated with intralesional steroids, topical steroids, topical tofacitinib, and pulsed dexamethasone. In December 2020,  photographs revealed about 70% of hair loss in the scalp and more than 50 % of loss of his eyebrows and eyelashes. The patients provider has recommended treatment with Xeljanz. Per the medical literature, in patients with severe alopecia, aggressive treatment is supported. Meah and colleagues reported that JAK inhibitors are the ideal choice of systemic therapy in adults. This patient has chronic alopecia areata that has progressed to totalis. He has failed typical first-and second-line therapies and current medical literature supports the use of JAK inhibitors as the next ideal choice for therapy in this clinical setting. For these reasons, the requested Xeljanz 5 mg tablets is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg tablets is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The parent of a three-year-old male enrollee has requested for early childhood partial hospitalization program services for treatment of the enrollees autism. Findings:  The physician reviewer found that Applied Behavioral Analysis (ABA) in the home and parent education would seem to be a more suitable an approach to this childs problems. The hospitalization and its duration (far longer than a typical period of observation) appear to be of doubtful long-term benefit.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old male who has requested continuation of intravenous antibiotic (IV) therapy for Lyme disease.  He was started on IV ceftriaxone (Rocephin) in February 2006.  The patient stated that he was bitten by a tick in August 2004 and diagnosed with Lyme disease in February 2006.  He reported that his symptoms included tremors in the hands, numbness, weakness and cramping of the right forearm, brain fog, moderate to severe fatigue, stiff neck, migrating arthralgias, arthritis of the left hip, poor concentration and light headedness.  The patient also reported that his symptoms had improved during treatment with IV ceftriaxone.The providers notes are brief.  In February 2006 he reported the patient had fatigue and joint pain along with muscle weakness, and IV ceftriaxone was started at that time.  The patient was afebrile and the physical examination was described as normal.   In March 2006 the provider noted that the patient was 30% better and indicated positive tests for human herpes virus 6 and EBV without additional details or lab reports.  In April 2006 the provider noted that the patient was being given 4 grams per day of IV ceftriaxone four days per week.  Foggy thinking, hand tremor and joint pain are recorded as symptoms and the provider stated the patient was overall better. The providers note from April 2006 indicated the IV ceftriaxone therapy was being continued and that the patients symptoms were improving.  The Lyme IgG Western Blot is negative as is the Lyme IgM Western Blot, both done in January 2006.  The IgM is reported as positive by the testing laboratory, but noted to be negative by CDC criteria.The patient has requested authorization for continued treatment with IV ceftriaxone. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The evidence provided does not lead to a diagnosis of Lyme disease, nor is there clinical documentation of arthritis or other physical findings consistent with the diagnosis.  While the patient apparently has a photo of a bulls-eye rash, we do not have physician notes about the patients initial care following the tick bite.   The CDC approach remains the accepted route to a serological confirmation of Lyme disease.  In this case, only Western Blots were done and both were negative by the standard criteria.  Because the diagnosis was not substantiated, treatment with IV ceftriaxone for greater than 30 days is not necessary.  It is only in cases of documented cardiac or neurological disease that extended treatment is warranted.  The Krupp study cited above concluded that due to the significant adverse effects associated with antibiotic therapy, there is no indication for IV ceftriaxone therapy for patients with Lyme disease who complain of fatigue.   Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested residential treatment services for treatment of his panic disorder with agoraphobia and major depressive disorder, recurrent, moderate.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of residential treatment level of care. Although the patient had had a transient response in the past, it appears that residential treatment had been unsuccessful in producing a sustained result. The history obtained does not indicate any risk to self or others. During the course of his stay, he took passes for up to a week, with no reported adverse incident.  While the patient appeared to improve during the course of his stay at the residential treatment center, the admitting history indicates that his Emsam dose had just been maximized, and that his family was reporting significant improvement on this medication prior to admission. American Psychiatric Association practice guidelines indicate that patients with major depression and panic disorder should be managed in the least intensive setting which is likely to be safe and effective. All told, residential treatment services provided durnig the time periods at issue were not medically indicated for the treatment of this patient. As of the initial time period, the patient could have been safely and effectively managed in the context of continued outpatient treatment with medication management and psychotherapy directed towards continued processing of the issues underlying his anxiety.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Benicar for treatment of his hypertension. Findings:  The physician reviewer found that the American Heart Association, American College of Cardiology, and American Society of Hypertension 2015 scientific statement for the treatment of hypertension in patients with coronary artery disease recommends the use of an angiotensin II receptor blocker or angiotensin converting enzyme inhibitor as part of a regimen in patients with hypertension and chronic stable angina if there is prior myocardial infarction, left ventricular systolic dysfunction, diabetes mellitus, or chronic kidney disease.  In this case, the documentation suggests that the patient has had a distant myocardial infarction and current hypertension.  Recently, a cardiac stress echocardiogram was normal.  The patients blood pressure is well-controlled.  The documentation submitted for review does not support that the patient has tried and failed treatment with one of the Health Plans formulary drugs.  According to the documentation, the patient has not had adverse drug reaction to other antihypertensive medications tried or suggested by the Health Plan. 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.