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

A 51-year-old female enrollee has requested inpatient psychiatric services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that this patient presented with acute symptoms characterized by depressed mood, anxiety, poor sleep, suicidal ideation and a history of a psychotic break. The patient was unable to work. Suicide precautions were initiated on admission. The presence of a mood disorder, disorganized thoughts with suicidal ideation, and a history of psychosis, along with the presence of insomnia and anxiety, increase the risk of suicide (as noted in the American Psychiatric Association Practice Guidelines cited above). Therefore, acute hospitalization was warranted and medically necessary in order to initiate suicide precautions, monitor for safety, assess sleep, and assess reality testing and coping skills in a safe environment until the patient was clinically appropriate to discharge to a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for immunotherapy with nivolumab (Opdivo). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees grade IV glioblastoma. Although multiple trials are testing various forms of immunotherapy in patients with glioblastoma, published data remain limited. In a phase I trial investigating the safety of monotherapy or combination therapy with two checkpoint inhibitors, 40 patients received either Opdivo with or without ipilimumab. Overall, monotherapy with Opdivo was better tolerated than combination therapy. However, the authors concluded that further studies are needed to help select patients most likely to respond to checkpoint inhibitor immunotherapy. Available standard therapies include retreatment with temozolomide and low-intensity alternating electric fields, which have more data to support them than Opdivo in this clinical setting. Accordingly, the requested Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee requested hyperthermic intraperitoneal chemotherapy (codes 77605 and 96446) for treatment of her ovarian cancer.   Findings:  Two physician reviewers found that The National Comprehensive Cancer Network guidelines do not include the use of hyperthermic intraperitoneal chemotherapy in their recommendations for management of ovarian cancer. Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option, specifically in cases where surgical debulking was suboptimal.  The current medical evidence has not established the superior effectiveness of hyperthermic intraperitoneal chemotherapy in this clinical setting.  Helm and colleagues noted that further research is needed.  There is a lack of high quality prospective trials showing benefit over standard of care.  Thus, hyperthermic intraperitoneal chemotherapy is not likely to be of greater benefit than other alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested Abraxane chemotherapy for the treatment of his metastatic melanoma. Findings:  Three physician reviewers found that Abraxane is an albumin-bound form of Taxol. It is approved for use in metastatic breast cancer and is being actively studied in many other tumor types, including melanoma. There is one published abstract submitted with the appeal. There were partial responses noted, particularly in patients that were previously untreated with chemotherapy. As far as can be determined, there is nothing beyond an abstract published as yet. The data for the use of Abraxane in melanoma is therefore quite minimal, and the evidence in terms of survival benefit is lacking.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested  for residential treatment services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the records indicate that the patient was at imminent risk of serious harm to self or others as documented in the mental status examination. Based on review of the records, this patient meets the American Psychiatric Association (APA) guidelines for admission to RTC during the period under review and thus the admission was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old woman with intractable chronic daily headache requesting coverage for Actiq. The patient has been evaluated at multiple pain clinics and has failed usual acute and chronic therapies. She has been using Actiq for three years with improvement in her condition including reduction in emergency room visits and the ability to stay employed. She has requested authorization and coverage for Actiq, which has been denied by the Health Plan.Review of the submitted clinical evidence demonstrates the patient has chronic migraine likely complicated by medication overuse headache. She has failed standard therapy. The patient has tried a variety of short and long-acting narcotics and found Actiq affords her the best control of her headaches. Given the documented failure of other available treatments and the demonstrated improvement with Actiq, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested intensive outpatient treatment, psychiatric, adult and geriatric treatment services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the services at issue are medically necessary for treatment of the patients medical condition. The medical literature does not definitively recommend particular treatment settings for the delivery of evidence-based therapeutic interventions.  However, as in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. The patient failed the outpatient level of care. During the episode of illness, his symptom burden prompted suicidality and necessitated an acute psychiatric hospitalization.  The patient has been engaged in active treatment using evidence-based therapies for his condition.  The patient has improved with the disputed service.  The patients psychiatrist recommended continued treatment at the intensive outpatient level of care while the treatment team developed a plan that included family involvement and quantifiable goals with a tapering of services and plan of discharge to the outpatient setting with follow-on services provided by his program therapist. This plan of care is reasonably expected to improve the patients condition, facilitate a successful transition to the outpatient setting and prevent a more serious episode of illness that would more than likely require treatment at a higher level of care.  Thus, intensive outpatient treatment, psychiatric, adult and geriatric treatment was and is medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: There is limited high-grade literature regarding the efficacy of various conservative management options in the setting of knee pain attributed to chondromalacia patellae and patellofemoral pain syndrome. There is some low-grade evidence that exercise is better than no exercise for the pain related to these conditions. However, there is a lack of data that there is demonstrable functional improvement with exercise. There is also no clear indication what types of exercise may be most appropriate, although strengthening of the hips and quadriceps is generally recommended. Given this patients prior treatment and progress, these exercises do not require additional formal physical therapy services. The patient underwent sufficient therapy to have been transitioned to an independent exercise program. Moreover, she does not have impairments that would preclude performance of an appropriate independent exercise program. While she has continued to have symptoms and poor tolerance to independent exercise, formal therapy is not expected to improve her clinical course or outcomes. Thus, the requested physical therapy is not medically necessary for treatment of this patients knee pain. 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: Upheld

The patient is a 42-year-old woman who is status post gastric bypass. The patient has lost approximately 150 pounds since the surgery, resulting in excess skin. She has requested authorization and coverage for an abdominoplasty with panniculectomy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.Based upon the available medical data, the procedure of abdominoplasty and panniculectomy is not medically necessary. The submitted medical records include no mention of intertrigo, skin ulcerations or cellulitis that has been refractive to conservative medical management. Furthermore, there is no documentation in the submitted medical records that the patients activities of daily living have been affected due to her condition. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz injections. Taltz injections are not a standard treatment in this patients case. The standard treatment of rheumatoid arthritis includes both nonpharmacologic treatment and pharmacologic therapy. Medications for rheumatoid arthritis include nonsteroidal anti-inflammatory drugs, glucocorticoids and disease-modifying antirheumatic drugs (DMARDs). DMARDs encompass a heterogeneous group of antirheumatic medications, including interleukin-6 receptor antagonist antirheumatic medications. Taltz is an anti-interleukin 17A monoclonal antibody. Taltz has been approved by the U.S. Food and Drug Administration for the treatment of plaque psoriasis and has shown efficacy for psoriatic arthritis. The records do not document that the patient has psoriasis or psoriatic arthritis. This patient has diagnoses of rheumatoid arthritis and fibromyalgia. Taltz has not been approved by the U.S. Food and Drug Administration for the treatment of either rheumatoid arthritis or fibromyalgia. The current medical evidence does not support the requested medication in this clinical setting. Therefore, Taltz injections are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)) performed in conjunction with a bilateral mastectomy. Findings:  The physician reviewer found that a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). WPATH states that medically necessary gender affirming/confirming surgeries may include bilateral mastectomy and chest reconstruction, as appropriate to each patient. Mastectomy with male chest reconstruction in transgender males is now commonly done in young adults and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. A recent study of adolescents and young adults concluded that chest dysphoria was high among presurgical transmasculine youth, and that surgical intervention positively affected both minors and young adults.In this case, the patient has a long history of gender dysphoria, and he has been living as a male, on testosterone. The patient has substantial documentation from licensed mental health providers of gender dysphoria regarding his chest and documentation of clinically significant symptoms supporting the medical necessity of chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)), performed in conjunction with a bilateral mastectomy. Additionally, the fasciocutaneous flap is considered a necessary part of the chest reconstruction by this surgeon due to more extensive dissection of the abdomen and lateral chest. Under these circumstances, the requested chest reconstruction (CPT code 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk)), performed in conjunction with a bilateral mastectomy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: The patient has requested authorization and coverage for Brand name Herceptin. Per the National Comprehensive Cancer Network (NCCN) guidelines, biosimilar agents for trastuzumab (Herceptin) are endorsed as standard substitutions. In addition, U.S. Food and Drug Administration (FDA) approved biosimilar agents, such as Kanjinti, are appropriate substitutes for brand name Herceptin. Oftentimes, patients with HER2 positive metastatic breast cancer can develop progression of disease and need to be changed to different medications. Based on current recommendations, brand name Herceptin is not supported for treatment of this patient when biosimilar agents are available to provide control over this patients disease. Therefore, the requested brand name Herceptin 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 53-year-old female enrollee requested functional endoscopic sinus surgery (FESS) for medical treatment of her chronic sinusitis.  Findings:  The physician reviewer found that patients with symptoms of recurrent, refractory and chronic rhinosinusitis should have documentation of medical therapy for at least four weeks including antibiotics. Medical therapies including intranasal topical steroids, oral steroids, antibiotics, and other medications should be documented including the results of those medical treatments. Although the patients surgeon reported that the patient received a course of levofloxacin, the patients response to that therapy was not provided for review. In addition, there is no documentation showing the patient received antibiotics or results of the treatment. In the absence of documentation of prior medical therapies and response to those therapies, the medical necessity of the services at issue has not been established in this clinical setting.  Therefore, the services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an five-year-old female enrollee has requested speech therapy for treatment of the enrollees speech disorder.  Findings:  The physician reviewer found that the enrollees tongue thrust was identified through the observation of the speech therapist and the articulation disorder was objectively evaluated with the Goldman Fristoe Test of Articulation. The therapist also documented that the patient could manage all consistencies of food and liquid despite the tongue thrust. The majority of the literature available regarding tongue thrust describes this condition in regard to articulation deficits. There is limited literature supporting the use of speech therapy in the treatment of a dysfunctional swallowing pattern, and what does exist is inconclusive as to efficacy. This is especially true when all textures of food and liquid are managed. Additionally, there is no medical documentation that the tongue thrust is related to a disease, illness or injury.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year ten-month old male born the product of a term delivery who appeared to be developing normally until he was started in daycare/preschool. At that time it was noted that his language was not age appropriate. The patient was referred to a pediatric neurologist who documented expressive language delays and mildly reduced tone. The patient has also been seen by a speech therapist who diagnosed him with speech apraxia. An initial evaluation has been submitted along with daily progress notes. No follow-up formalized testing has been performed and none of the provided documentation reports a diagnosis of speech apraxia.At issue is whether speech therapy is medically necessary for treatment of the patients condition.Upon review of the relevant literature, there is no new evidence regarding the cause of developmental apraxia of speech. To date, the etiology remains unclear. Therefore, this condition is considered a developmental abnormality and does not represent a condition associated with a specific illness or injury. Thus, speech therapy in this setting is educational in nature and is not medically necessary. Accordingly, 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

Nature of Statutory Criteria/Case Summary:The patients parent has requested authorization and coverage for Norditropin FlexPro 15 mg/1.5 mL pen injector for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is receiving growth hormone therapy for short stature. However, the records do not demonstrate that she is growth hormone deficient. There is no information on current height, past height and weight trajectory, or predicted adult height prior to treatment. There is no current bone age assessment to document that epiphyses remain open. The records do not document that all other causes of short stature were ruled out prior to initiation of growth hormone therapy. The current medical evidence does not support the requested medication in this clinical setting. All told, Norditropin FlexPro 15 mg/1.5 mL pen injector 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 pediatrics with sub-specialty 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.