Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested authorization and coverage for Interstim therapy surgery for treatment of the enrollees mixed incontinence.  Findings:  Two physician reviewers found that the patient has a history of pelvic pain, urinary frequency, urgency and frequency.  She has a history of mixed incontinence, with both stress and urge associated incontinence. She has also had persistent pain and has undergone hydrodistention of the bladder. The patient has been tried on Elmiron and anticholinergics and the medical documentation states these therapies were not successful. Interstim therapy surgery was recommended as a result of the patients urethral instability, as seen on the urodynamic testing. The patient has requested authorization for treatment with Interstim. The patients history is complex and her symptoms are numerous. The cause of her symptoms may be multifactorial. Interstim is an effective treatment for urinary urge incontinence and studies have shown durable responses to this device (McGee, et al.; and Spinelli and Sievert). The literature is not as robust in cases of mixed urinary incontinence, such as is the case with this patient. Ghazwani, et al. reports that patients were qualified for permanent Interstim therapy by showing a 50% or more improvement in their bladder pain and voiding parameters symptoms after a percutaneous nerve evaluation (PNE). However, this was a small study and additional studies are required to assess the durability of this modality for treatment of the patients condition. All told, there is limited evidence in the available peer reviewed medical literature that Interstim is likely to be more efficacious in this clinical setting than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hematopoietic progenitor cell autologous transplantation. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. The disease is characterized by multifocal inflammation of the central nervous system, which causes impaired nerve conduction. The most common form of multiple sclerosis is the relapsing and remitting subtype, which clinically refers to episodes of new or worsening functioning with magnetic resonance imaging (MRI) correlation and periods of clinical stability. As noted in the medical literature, there are several therapies available to manage the disease. While there is evidence to suggest stem cell transplantation is effective for patients with multiple sclerosis, there is a lack of well-designed randomized controlled trials and studies comparing stem cell transplant with the available therapies. Further, the studies lack data on the long-term safety of this therapy. He has tried and either had poor effectiveness or adverse effects with other medications. The records suggest that this patient has stable disease on MRI with Tysabri. Given these findings, the requested hematopoietic progenitor cell autologous transplantation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found that the requested services are not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Medical professional reviewers 1 and 3 are board certified in neurology and are actively practicing. Medical professional reviewer 2 is board certified in oncology 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: Upheld

A 41-year-old female enrollee has requested adult substance abuse inpatient acute care and the residential treatment center rehabilitation services for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is inadequate support establishing the necessity of an acute inpatient level of care. With regard to the residential treatment services provided on the said date, the clinical records also do not establish that the patient required the intensity of this level of care. Based on the medical records provided, this patient was not experiencing suicidal ideation during this period and had no signs of withdrawal. Thus, she was not a danger to herself or others at any time during her residential stay. In addition, she was not acutely psychotic and did not have a past history of any psychotic behavior. There is also a lack of documentation of adequate treatment attempts at less intensive therapeutic options such as partial hospitalization or intensive outpatient therapy programs. Further, the records indicate the patient was motivated for treatment and had a supportive environment, which would have made her appropriate for a less intensive level of care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male has requested coverage for past emergency services provided for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based upon the history reported to the admitting facility from the referring provider, a prudent layperson would consider the admission to be an emergency admission. Specifically, the patient was reported to have intentionally injured himself by cutting, smashing his foot with a rock, and trying to fall down a mountain and furthermore was threatening to hang himself. After 48 hours of observation, there was no further evidence of an emergency. A psycho-social assessment states that, he presented in a positive mood, due to being so relieved he was no longer in wilderness. Finally, the patient denied any current suicidal ideation and denied any thoughts of self-harm. A suicide risk assessment noted that the patient hyped it up to get out of the wilderness program. There are no notes in the treatment record of any threatened or actual harm to self or to others. Overall, based upon the patients history of risk of harm, the patients condition merited an emergency admission. However, by the second day of admission, it started to become apparent that he had exaggerated his suicidal thoughts and actions in a successful effort to be released from the wilderness program. After the second treatment day, he could no longer be considered to be at risk to himself or others. Therefore, the admission would be considered by a prudent layperson to be an emergency admission. After 48 hours of observation, it could be concluded that no true emergency existed. As such, only the admission and first 48 hours of treatment can be considered an emergency admission.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for an oral appliance. The patient has been diagnosed with mild obstructive sleep apnea (OSA). Researchers reported that they recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. They also reported that an oral appliance can be an effective treatment option for those with OSA and snoring. In this case, the patient has been diagnosed with OSA and was unable to tolerate treatment with CPAP. The patients periodontal health was noted to be grossly normal. The provider noted a panograph and revealed normal temporomandibular joints with no signs of pathology. The medical evidence supports the device at issue in this clinical setting. Therefore, an oral appliance provided on was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device at issue was 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 otolaryngology with sub-specialty certification in sleep 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

A 42-year-old female enrollee has requested reimbursement for air ambulance services for treatment of her pneumonia.  Findings:  The physician reviewer found that a progressive multilobar pneumonia with a failure to establish a diagnosis and/or prognosis constitutes a medical emergency. A diagnosed bacterial pneumonia in a community-acquired setting has approximately a 5% mortality rate. For hospitalized patient, the mortality is increased to 15%. The general expectation is that an otherwise healthy individual should improve within one to three days of treatment. That did not occur in this instance, nor was a reasonable diagnosis established. In fact, the treating physician stated a need for air transport due to his concerns regarding the infectious and potentially contagious nature of the patients condition. The inability of the treating facility to provide a diagnosis and/or prognosis along with apparent radiographic and clinical evidence of the patients failure to improve, constituted a medical emergency situation and a need for medical transport. Land travel would not have been appropriate for a patient with a progressive lobar pneumonia, given the distance. There was no reasonable alternative mode of evacuation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior optical coherence for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that anterior optical coherence tomography was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Anterior optical coherence tomography is indicated for complex cases of angle closure glaucoma to elucidate the pathophysiology of the angle closure. This test can show the exact anatomic features responsible for the closure, which gonioscopy cannot show. Anterior optical coherence tomography is particularly effective for patients with plateau iris syndrome, as this testing is able to make a diagnosis after peripheral iridotomy has failed. Also, anterior optical coherence tomography is utilized to follow patients long-term to monitor the configuration of the iris root and ciliary body. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in ophthalmology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for one day inpatient hospital stay for treatment of the enrollees concussion. Findings:  The physician reviewer found that the inpatient admission was not medically necessary for treatment of this patients medical condition. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the provider anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care.  At the time of admission, the patient did not report any loss of consciousness or alterations in baseline mental status. There were no bleeding and no urgent procedures that would have warranted an acute inpatient setting. 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 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

A 28-year-old female enrollee has requested medical services  for the treatment of her rectal evacuation pelvic floor disorder. Findings:  The physician reviewer found that chronic pelvic pain and gastrointestinal dysfunction can lead to dysfunction and dysynergia of the pelvic floor muscles. Pelvic floor dysfunction can likewise lead to pain and worsening gastrointestinal dysfunction. Pelvic floor PT has been shown to help improve muscle function and relieve pain. Trigger point injections have been shown to relieve pain at specific trigger points. The use of PT on the pelvic floor should be used for a finite period of time, as with this patient, until maximum improvement has been obtained. Therefore, the services at issue including the patients office visit for evaluation, manual treatment, trigger point injections, and PT evaluation, were all medically necessary as the patient was clearly functionally impaired and there is documented evidence that these services resulted in clinical improvement.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has tip rhinoplasty for treatment of the enrollees nasal deformity. Findings: The physician reviewer found that the tip rhinoplasty has not been established as medically necessary or reconstructive in nature for treatment of the patients medical condition. Based on the documentation provided, the rhinoplasty did not address the patients partial nasal obstruction. Cephalic trim and dorsal hump resection are consistent with cosmetic intervention, as well as the lateral osteotomies. Typical interventions for reconstructive principles include, but are not limited to spreader grafts, septoplasty, turbinectomy and other grafts. On previous evaluation, the initial provider had documented evidence of traditional findings associated with nasal airway obstruction, including septal deviation and large turbinates. Turbinectomy and septoplasty were not contained in the operative note. Although, the patient had a functional deficit possibly related to her septum and enlarged turbinates, the procedure did not address these concerns. In sum, the patient had functional impairment that could have been addressed with surgical intervention, but the tip rhinoplasty did not address the patients functional impairment. In addition, the patient did not have a significantly abnormal appearance based on the photographs and medical documentation submitted for review. The patients appearance was relatively normal and the surgical intervention performed was to improve the patients appearance.Final Result: The reviewer determined that the surgery at issue was not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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

The patient has requested authorization and coverage for Soolantra cream. Rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. U.S. Food and Drug Administration (FDA) approved treatments include topical metronidazole and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and anti-infection treatments. Since this patient has failed standard treatments, the next step to therapy should include the anti-Demodex cream Soolantra. Given these findings, the requested Soolantra cream is medically necessary for treatment of this patient. 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 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 12 weeks for treatment of his chronic hepatitis C virus genotype 1b. 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 guidelines, patients with cirrhosis are considered high priority for therapy. The patients ultrasound is accurate for diagnosis of cirrhosis. Per guidelines, treatment naive cirrhotic genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni for 12 weeks 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for iron dextran, 50 mg x 20 units (for a total of 1000 mg). It is generally accepted practice to target normal iron saturation and ferritin levels before stopping repletion. In this case, the records demonstrate that the patient does not have anemia but does appear to have low iron stores despite taking oral iron, indicating that further repletion is necessary. In this clinical setting, the patient may be maintained on oral iron with follow-up of her iron indices and blood hemoglobin and complete blood counts. A lack of improvement after two months in iron stores or indices, such as the saturation and ferritin, may indicate that the patient is not absorbing oral iron. Given that the patient appears to have recovered from anemia and additional time on oral iron may replete her iron stores, the requested medication is not medically indicated at this time. Therefore, iron dextran, 50 mg x 20 units (for a total of 1000 mg) 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 internal medicine with sub-specialty certification in 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Cosentyx 300 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients hidradenitis suppurativa (HS) with Hurley state 3, synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. The submitted documentation does not support the medical necessity of the requested medication. The patient is requesting coverage for Cosentyx for treatment of hidradenitis suppurativa. The patient has tried and failed multiple therapies, including Humira, doxycycline, isotretinoin and zinc. Cosentyx is an injectable biologic, which is U.S. Food and Drug Administration approved for the treatment of psoriasis. However, the U.S. Food and Drug Administration has not approved an indication for hidradenitis suppurativa. The medical literature reveals a limited number of case reports of patients who have shown improvement of hidradenitis with Cosentyx. Currently, its use in hidradenitis suppurativa would be considered of unproven efficacy. There is insufficient medical evidence from controlled studies to show the benefit of this medication for this condition. Therefore, Cosentyx 300 mg 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 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.