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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested disc replacement in the lower spine and adjustment of the surgically replaced right shoulder for treatment of his medical condition.  Findings:  The physician reviewer found that the request for disc replacement in the lower spine is not medically necessary for treatment of the patients medical condition. Evidence based medical guidelines have not been met for disc replacement for this patient. Therefore, the requested disc replacement in the lower spine is not medically necessary for treatment of this patients medical condition.  In addition, detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Therefore, the requested disc replacement in the lower spine is not medically necessary for treatment of this patients medical condition.  In addition, adjustment of the surgically replaced right shoulder is not medically necessary for treatment of the patients medical condition. The peer review literature supports conversion to reverse shoulder arthroplasty for failed shoulder arthroplasty, with consideration of patients age and failed conservative treatment. The patient is status post right shoulder replacement with worsening right shoulder pain. However, there is no radiographic evidence of hardware complications.  Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Therefore, the requested adjustment of the surgically replaced right shoulder is not medically necessary for treatment of the patients medical condition. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to researchers,  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 2 patients should be treated with Mavyret. These recommendations apply regardless of fibrosis stage. Researchers trial showed a 99% cure rate with treatment. Data shows reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret to treat the patients hepatitis C is supported as medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy, one time per week for 60 minutes, for treatment of the enrollees developmental language delay.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The patient had considerable delays in both receptive and expressive language.  Based upon the submitted evaluations, she has gone from demonstrating moderate delays to above average language.  However, this would be difficult to achieve.  Of note, the speech therapy goals included following two-step unrelated directions without gesturing, which is not a typical goal for a patient with above average language skills.  Given the clinical documentation, an updated evaluation with another method of testing is needed in order to establish the medical necessity of the requested speech therapy.  The evaluation for articulation problems may be difficult.  The records document concerns regarding conversational language and language with peers.  All told, the requested speech therapy, one time per week for 60 minutes is not medically necessary for the treatment of this patient based upon the information provided at this time.  Final Result: The reviewer determined that the requested therapy 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 developmental-behavioral pediatrics 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: This dermatologist diagnosed the patient with chronic ulcerative colitis that is being treated with Humira since 2015, and that psoriasis is listed as a side effect of Humira. Further notes report that the patient has greater than 20% body surface involvement with active, scattered psoriasis. The physician reports that Otezla samples tried in August 2019 were beneficial and recommends that Otezla treatment for psoriasis continue, along with Humira for her colitis. At issue is whether the requested medication, Otezla 30 mg tablets, is medically necessary to treat the patients medical condition. A known side effect of Humira is plaque type psoriasis, which this patient has acquired. Otezla has been effective for this patients psoriasis. The patient is not being treated with Humira for psoriasis; she is being treated with Humira for ulcerative colitis. Humira and Otezla are being used for two different conditions. Literature reports that Otezla can safely be combined with biological medications, such as Humira, for patients with psoriasis.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Cialis (30 tablets for a 30 day supply) for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication dosage. Coward and Carson report recent studies show a significant treatment benefit from once-daily, low-dose tadalafil. This requires at least 30 tablets per month to be effective.  Therefore, the medical necessity of the requested medication dosage has been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees hepatitis C. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

The patient is a 45-year-old female diagnosed as having fibromyalgia for approximately one and a half years. She first began treatment for this condition in July 2004 and received treatment until May 2005. The patient indicates she had symptoms six months prior to beginning acupuncture treatment. A request has been made for continued acupuncture and trigger point injections, which has been denied by the Health Plan.It appears the patient first received treatment for fibromyalgia in July 2004, which involved trigger point injections, massage and acupuncture. Based upon the records provided, it appears the patient has had approximately 39 treatments; 15 of these treatments involved acupuncture in addition to massage and trigger point injections. It appears the patient has been seen approximately once weekly from July 2004 through May 2005 for treatment of fibromyalgia with some lessening of symptoms. There is no indication the patient received acupuncture in April and May of 2005; it appears she only received massage and trigger point injections during that time. Based upon the information provided, the patient has not had acupuncture since March 2005, and there has been no worsening of symptoms. As such, continued acupuncture is not medically necessary at this time. Furthermore, the frequency of the patients trigger point injections appears excessive. The patient has been receiving injections on approximately a weekly basis. Although the injections have helped to lessen the severity of the patients symptoms, the frequency of the injections appears excessive. Therefore, while additional trigger point injections are medically indicated, it would be reasonable and appropriate to reduce the frequency of the trigger point injections to every other week for a two-month period. The patient should be re-evaluated at the end of the two-month period to determine if additional trigger point injections are indicated.Accordingly, I have determined that although the requested acupuncture is not medically necessary for treatment of the patients medical condition, additional trigger point injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Findings:  Three physician reviewers found in this patients case, the records document melanoma which was known to be at high risk for recurrence based on the pathology. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. Despite the patient having high-risk results, treatment and surveillance recommendations were not likely to have been altered from those dictated by the pathology. Therefore, DecisionDx-Melanoma testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 patient is a six-year-old male with a diagnosis of attention deficit hyperactivity disorder (ADHD) and autism. He has been receiving speech therapy for treatment of autism. The patients therapist has recommended that speech therapy be continued. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients condition.There is very little literature regarding auditory processing, autism, and speech and language in the area of pragmatics. Most of the evidence involves single case studies or cohort designs with no randomization or blinding. There is still controversy regarding the existence of auditory processing as a distinct disorder. With regard to autism, the only treatment that has been shown to be beneficial is applied behavioral analysis. Furthermore, the issue of pragmatics is considered a learning disability.Upon review of the submitted speech therapy reports the goals outlined in the September 2003 report do not appear to be adequately documented. Based on this documentation, it is not possible to determine if the goals have been met, not met or abandoned because the goals from the July 2004 report in no way correlate to the previous goals.Thus, the medical need for continued speech therapy is not supported by the medical literature or by the patients prior experience with speech therapy. Therefore, I have determined that 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. McClintock and colleagues note that there is an abundance of data pertaining to the safety and efficacy of TMS for individuals with major depressive disorder. The American Psychiatric Association (APA) guidelines for the treatment of major depressive disorder recognize the safety and efficacy of TMS in the treatment of patients with a prolonged course of depression. In this case, the records document treatment refractory depression, as the patient has failed three antidepressant trials in addition to psychotherapy. The provider has recommended treatment with TMS.  While the Health Plan indicates that the patient is diagnosed with bipolar disorder due to a prescription of Lamictal, the records note that the patient has been diagnosed with recurrent and severe major depressive disorder. Lamotrigine is prescribed as an adjunct for refractory depressive symptoms, based on the established treatment algorithms, and does not indicate that the patient has a diagnosis of bipolar disorder. Given that current medical literature supports the use of TMS for the treatment of refractory depression, the requested services are medically indicated. In this patients case, TMS is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS services  are 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing. In the peer-reviewed medical literature, it states that, to demonstrate the true clinical benefit of genotyping for predicting treatment response or adverse effects, it would be necessary to conduct prospective head-to-head comparisons of different specific treatments chosen by genotype, which have not yet been performed., it was noted that phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. There are some circumstances that genetic testing is done for safety reasons such as with treatment with carbamazepine. This patients documentation does not report that this medication is a consideration. Thus, the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genotype testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or to others.  She was medically stable.  She was cooperative and respectful.  There was no indication that returning her to her home environment would lead to decompensation.  The records do not demonstrate the need for structure of a 24-hour nature, and she could be managed at a lower level of care.  In sum, residential treatment was not and is not medically indicated 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 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: Upheld

The patient has requested authorization and coverage for Simponi. The U.S. Food and Drug Administration (FDA) approved Simponi for the treatment of patients with ulcerative colitis. This patient has failed three other anti-tumor necrosis factor alternatives for treatment of his Crohns disease. Other treatment was initially effective, until the patient developed antibodies. Given the findings in current medical literature, the requested Simponi 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stage I level anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed same day by stage II posterior revision laminectomy at L4-L5 with laminectomy extending into the L3-4 segment and laminectomy of L5-Sl with posterior spinal fusion from L5-Sl with instrumentation at L5-S1. The submitted documentation supports the medical necessity of the requested services. This patient has a history of spinal stenosis with adjacent segment disease following a laminectomy and subsequent single level fusion at L4-5. The literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability.  In this case, there is evidence of adjacent segment disease with spinal stenosis and neurogenic claudication. As such, wide decompression will be necessary. Additionally, this will necessitate a fusion at L5-S1. Therefore, the requested anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed the same day by posterior revision laminectomy at L4-5 with laminectomy extending into the L3-4 segment, and laminectomy of L5-S1 with posterior spinal fusion from L5-S1 with instrumentation at L5-S1 is medically indicated. Thus, the requested stage I level anterior lumbar interbody fusion at L5-S1 with structural allograft and anterior fixation and demineralized bone allograft, followed same day by stage II posterior revision laminectomy at L4-L5 with laminectomy extending into the L3-4 segment and laminectomy of L5-Sl with posterior spinal fusion from L5-Sl with instrumentation at L5-S1 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 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.