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

A 57-year-old female enrollee has requested Victoza 3-Pak 0.6mg/0.1 pen for treatment of diabetes.  Findings:  The physician reviewer found that it is medically appropriate that the patient fail a trial of Byetta prior to coverage for Victoza. Based upon the submitted documentation, it is unclear if the patient took Byetta, and, if so, the length of time which she took this medication. Additionally, the physicians notes do not document specific side effects from Byetta.  The prescribing information for Victoza indicates that there is limited experience regarding the use of this medication for patients with mild, moderate and severe renal impairment. The prescribing information notes that the requested medication should be used with caution in this patient population. In this patients case, her estimated GFR was 35, and Victoza may be of questionable safety in patients with a low GFR.  All told, based upon the submitted documentation, the medical necessity of Victoza 3-Pak 0.6mg/0.1 pen has not been established for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Humira Pen 40mg/0.8mL Psoriasis Starter Kit followed by maintenance dosing. Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis note that three classifications have traditionally been used to determine psoriasis severity. The severity of psoriasis is generally defined by the total body surface area (BSA) involved, and BSAs of <3%, 3% to 10%, and >10% are considered as mild, moderate, and severe disease, respectively. According to a study, mild psoriasis is usually treated with topical therapies, such as corticosteroids or vitamin D analogues. For severe psoriasis, guidelines state that biologics are usually recommended. Another study performed a systematic literature search to assess therapeutic options for patients with psoriasis and concurrent inflammatory bowel disease (IBD). The study concluded that adalimumab demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. In this case, the patient has been diagnosed with severe psoriasis, with about 15% body surface area (BSA) affected. Records reflect that the patient was started on a mild-moderate steroid, triamcinolone, clobetasol, calcipotriene, and ketoconazole. While biologics would usually be recommended for severe psoriasis, the patient has a history of both psoriasis and ulcerative colitis, and the provider has recommended Humira (adalimumab) given its demonstrated efficacy for both conditions. Under these circumstances, the requested medication Humira Pen 40mg/0.8mL Psoriasis Starter Kit followed by maintenance dosing is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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 Harvoni for treatment of his 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 applies regardless of fibrosis stage or viral load. Per the guidelines, patients who have failed treatment with pegylated interferon and ribavirin are recommended to be re-treated with daily Harvoni for 12 weeks. This is based on multiple clinical trials.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male enrollee has requested Nutropin (somatotropin) for the treatment of the enrollees short stature. Findings:  The physician reviewer found that this patient is reported to have poor linear growth due to chronic glucocorticoid administration for asthma and thus does not, by definition, have idiopathic short stature.  Although his height is just below 2.25 standard deviations below normal for age and gender, he has a normal peak growth hormone response to clonidine, an IGF-1 level in the normal range, a normal bone age, and a pre-treatment growth velocity that was within the normal range. Thus, he does not meet criteria for classic growth hormone deficiency. Estimation of the final adult predicted height is limited by the fact that height measurement was not provided on the date of the bone age assessment, and bone age was still too young as of the said date to make use of the Bayley-Pinneau tables for prediction of final adult height. A lack of long-term longitudinal height data prior to six years of age and a lack of any longitudinal weight data make it difficult to assess long-term trends in growth. Although short-term improvements in growth velocity in children with glucocorticoid-induced suppression of growth have been demonstrated in uncontrolled studies, there is a lack of long-term data at this time. Larger, long-term studies are needed to determine efficacy and safety of growth hormone therapy in these populations of children, bearing in mind the potential of the combined use of growth hormone therapy and glucocorticoids to induce carbohydrate intolerance (Wilson and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for varicocele vein embolization.Findings: Three out of three physician reviewers found that varicocele vein embolization is not likely to be more beneficial for you than any available standard therapy.Per the guidelines on varicocele management, medical literature would support interventions to manage chronic testicular discomfort rather than assigning the source of pain to a varicocele that is not demonstrated on diagnostic evaluation. Medical literature shows treatment algorithm on a subclinical varicocele that is not present on imaging does not support repeat venography and embolization. Standard treatment protocols for testicular discomfort with medication (anti-inflammatory, or pain pathway disruptors such as tricyclics), direct nerve ablation via injection, or surgical denervation would be more likely to provide benefit in this patients case. In this case, the patient has persistent pain and short-lived pain resolution after both varicocele procedures. However, there was a lack of prominent visible recurrence or persistence on physical examination or venography. Therefore, varicocele vein embolization is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All 3 reviewers are board certified in board certified in urology. All reviewers 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a rhinoplasty. Functional rhinoplasty has proven to be an effective method for relieving nasal obstruction. By addressing specific structural abnormalities of the nose, nasal breathing can be improved. In a patient like this with a history of nasal trauma, nasal obstruction, deviation of the nose and deviation of the septum, specific maneuvers like osteotomies, septoplasty and placement of cartilage grafts can restore nasal breathing and create a normal appearance to the nose. This procedure is functional and is supported as medically necessary for this patient. Moreover, the condition constitutes an abnormal structure of the body. There is a deviation of the nose to the right and the septum to the left. These deformities impact nasal breathing. The patient does have a history of nasal trauma. The purpose of the surgery is to restore nasal anatomy to improve nasal function. This procedure will provide a more than minimal improvement in the patients appearance, as well. Given these findings, the requested rhinoplasty provided with the authorized septoplasty and turbinate reduction is reconstructive in nature and medically necessary. Final Result: The reviewer determined that the requested service is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstrutive 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: Upheld

The patients parent has requested authorization and coverage for Humatrope 24 mg. Based on the available documentation, this patient has a normal growth velocity at 4.81 cm per year based on height measurements. The provider noted that the patient has been following the 10th percentile on the growth chart. An absence of poor height velocity suggests normal growth. In addition, the patient is still pre-pubertal and her growth rate is expected to improve when she enters puberty. This patient does not meet the current U.S. Food and Drug Administration (FDA) approved indications for growth hormone (GH), because her height is not -2.25 standard deviations below the mean for age and sex. Moreover, the patients predicted adult height is within normal range for an adult female. All told, the requested Humatrope 24 mg 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 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: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Functional impairments due to a cerebral stroke can be severe to profound. Researchers found that while functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of the initial injury is a major factor influencing post-stroke motor recovery with implications for neurotherapy after brain injury. Additional medical literature shows that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher found that patients may improve spontaneously within the first three months and then more slowly in the coming year. While there is general consensus in current medical literature that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes, the data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages are poor. In this case, the patient sustained a stroke. The patient underwent extensive therapy but remained at a low level of function, requiring maximum to total assistance for basic self-care and mobility. The patients cognitive deficits contributed to their poor recovery. The patient was transferred for hospitalization for acute cholecystitis. They were subsequently discharged back to the skilled nursing facility, functioning at an even lower level. The records noted that the patient remained dependent for all care and mobility. In this case, the  given that the patients overall needs can be met at a custodial level of care, provided in a long-term care setting without rehabilitation or in the community by laypersons with minimal to no training at all, the services at issue were not and are not medically necessary for the treatment of this patient. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.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 overturned.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

An enrollee has requested reimbursement for right knee surgery.The patient had clinical exam findings that were consistent with imaging evidence of a complex medial meniscus tear and mild medial tibiofemoral compartment chondromalacia. The patient reported right knee pain with mechanical symptoms of locking and catching, and he was experiencing significant functional limitations in activities of daily living. X-rays in the pre-operative period documented well-maintained joint spaces in all three compartments. He reportedly failed conservative treatment, including activity modification, home exercise, and physical therapy. He underwent right knee surgery that included right knee arthroscopic partial medial and lateral meniscectomy, synovectomy of all 3 compartments, loose body removal and chondroplasty of all 3 compartments. Operative findings at the time of surgery documented a small lateral meniscus tear, grade chondromalacia changes in the undersurface of the patella, trochlear groove, lateral femoral condyle, medial tibial plateau, and lateral tibial plateau, grade changes in the medial femoral condyle, and loose bodies within the joint. Current evidence based medical literature supports surgical intervention for treatment of the patients right knee medical condition. The patients signs, symptoms and clinical exam findings were strongly correlated with imaging evidence of a complex medial meniscus tear. There was also no evidence of significant osteoarthritis in the right knee that would have precluded proceeding with repair of the meniscal tear. Records also indicate that there was a failure of reasonable conservative treatment. Under these circumstances, the right knee surgery at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential substance abuse treatment services for treatment of his medical condition. Findings: The physician reviewer found that upon review of the submitted documentation,  residential substance abuse treatment services were not medically necessary for treatment of the patients condition. During the period at issue, the patient was not at risk for imminent severe withdrawals. He was not experiencing significant post-acute withdrawal symptoms. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive factors to warrant continued residential treatment. The patient was motivated and engaged in the recovery process. He had family support.  All told, the patient no longer required 24 hour supervision at a residential level of care. The patients recovery could have continued at a lower level of care such as in a 12 Step outpatient program. As such, the services at issue 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 with sub-specialty certification in addiction 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: The parent of an enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that the progress notes indicate that the patient showed steady improvement in his anxiety symptoms throughout his residential stay. His anxiety attacks had decreased and he was able to manage these symptoms. The patient did not show any dangerous behaviors towards himself or to others. Progress notes indicate that the patients discharge plan included a PHP. It appears that the patient could have transitioned to a PHP. He was not displaying any significant or severe behavioral problems during the disputed period. The patient needs continued treatment to further improve his social functioning, anxiety, and paranoia. However, he no longer needed the restrictiveness of a residential psychiatric treatment facility as he had stabilized enough, over the three months of residential care at the facility, to transition to a less restrictive setting. Residential treatment is used for acute stabilization and is not evidenced based for long term type treatment as quoted in the following reference: Similarly, any gains made during a stay in residential treatment may not transfer well back to the youths natural environment, creating a cycle where children are often repeatedly readmitted.  Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry who recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. The medical evidence support residential treatment when used for acute stabilization. However, there is a lack of evidenced based reviews to support residential treatment for long term care as in this patients case. Children should be treated in the setting that is least restrictive and disruptive to their lives. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. Studies have shown that treatment outside of a residential setting are effective and appropriate and are as beneficial as RTC programs. The documentation provided supports treatment at a less restrictive setting. In sum, the RTC provided was not medically necessary for treatment of this patient. 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 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: The patient has requested authorization and coverage for brand name Copaxone. Findings:  The physician reviewer found that multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Characteristic of the disease is multifocal inflammation of the central nervous system, which causes impaired nerve conduction, leading to symptoms associated with the disease. There are several therapies that can manage multiple sclerosis. In addition to brand name formulation, there are generic formulations. Overall, there is a paucity of evidence in the medical literature that the brand name formulation of Copaxone is more effective with fewer side effects as compared to the generic formulation. Additionally, there are several available therapies that have proven efficacy and may be more beneficial for this patient than Copaxone. All told, the requested brand name Copaxone is not supported as medically necessary for treatment of this patients multiple sclerosis. Final Result: The reviewer determined that the requested brand name 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 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.