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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar gel 80 units for treatment of the enrollees lupus nephritis. Findings:  The physician reviewer found that the records indicate that this patient has been treated with first-line standard of care and has failed to experience an adequate response. The morbidity implications of persistent refractory proteinuria are significant. Acthar gel is U.S. Food and Drug Administration (FDA) indicated for nephrotic range proteinuria and has been used successfully to treat lupus nephritis. In the peer-reviewed medical literature, Researchers concluded that in patients with systematic lupus erythematosus, Acthar gel may provide significant disease activity reduction. Given this support, the requested H.P. Acthar gel 80 units is medically necessary for treatment of this patients persistent nephrotic range proteinuria. 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 nephrology 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: The patient has requested authorization and coverage for Norco. The Centers for Disease Control and Prevention (CDC) guidelines state that, clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards guidelines report that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The records provided for review document that this patient sustained a non-displaced left tibial fracture. The provider advised that the patient does not need to be evaluated for acute or subacute pain. The provider also reported that the patient is not a good candidate for opioid therapy since the benefits of treatment do not outweigh the potential risks. The records reviewed do not include a current Controlled Substance Utilization Review and Evaluation and System (CURES) report demonstrating continued compliance with her opioid regimen. The CDC guidelines recommend providers to discontinue opioid therapy in patients where the risks outweigh the benefits. Accordingly, the requested Norco 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 anesthesiology with subspecialty certification in pain management 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: Experimental/Investigational
Decision: Upheld

The parent of a 12-year-old male enrollee has requested biofeedback for treatment of the enrollees attention deficit hyperactivity disorder (ADHD).  Findings:  Two physician reviewers found that early research showed promise with the utilization of neurofeedback in the treatment of ADHD. A paper by Linden published in 1996 studied 9 children who received EEG neurofeedback and 9 children who did not receive EEG neurofeedback. None of the children studied were receiving medication. The author reported improvement in IQ and attention in the treated group.  Subsequent studies have been mixed. A recent study by Wangler and colleagues found that EEG neurofeedback reduced ADHD symptoms in a controlled randomized trial.  However, another recent study by Logemann and colleagues noted no improvement in a sham neurofeedback controlled study. Based upon the conflicting results in recent studies, further research is needed before the beneficial effects of neurofeedback in this setting can be confirmed. Given theinconsistencies in the available peer reviewed medical literature, neurofeedback remains an unproven modality for the treatment of ADHD at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee (HCPCS J7323). Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections received over several years, with the last series received in February 2020. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc injections in the right knee (HCPCS J7323) 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.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

The patient has been diagnosed with bilateral knee osteoarthritis, and is requesting authorization for Orthovisc injections in both knees.  Findings: Medical literature finds the use of HA is not supported due to the fact that most studies show that it does not show superiority over other treatments. Although current evidence-based research includes literature that does not strongly and definitively support the use of HA for the treatment of osteoarthritis, the medical records and documentation in this case supports improvement for this patients medical condition based on the previous viscosupplementation treatment.  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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested Electracorporeal Shockwave Treatment (ESWT) for the treatment of her plantar fasciitis. Findings:  Three physician reviewers found that ESWT is a non-invasive treatment for chronic proximal plantar fasciitis. It was FDA approved many years ago. Numerous studies have looked at the efficacy of ESWT. While there is not a definitive absolute efficacy rate, most studies show 60-80% effectiveness. Plantar fascia night splints and or intensive physical therapy have been shown to be 90% effective for treatment of plantar fasciitis. Endoscopic plantar fasciotomy also has a 90% effective rate, is minimally invasive, and has minimal risks and complications. In summation, ESWT is not likely to be more beneficial for treatment of the enrollees plantar fasciitis than other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old male enrollee has requested for artificial intervertebral disc replacement surgery for treatment of his back pain. Findings:  Two physician reviewers found that lumbar artificial disc replacement is still experimental for the treatment of lumbar degenerative disc condition. There are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long term. Fusion or non-operative management remains the gold standard treatment. Furthermore, outcomes with respect to two-level artificial disc replacement in the long term are not known.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Tramadol tablets,. In this case, the patient has chronic pain and lumbar radiculopathy that was aggravated in a recent motor vehicle accident. Physical examination revealed anterior thigh numbness suggestive of lumbar radiculopathy. The provider has discontinued Soma and started the patient on Cymbalta along with a course of physical therapy and weight loss program. This treatment regimen is consistent with the current guidelines regarding a multi-modal pain management plan. In addition, the provider recommended Tramadol, which is a less potent opioid than Norco, which was part of the patients prior treatment regimen. The requested dose of Tramadol twice daily is the morphine equivalent of 10 mg, which is below the recommended threshold for low dose opioid therapy. All told, the requested Tramadol, is medically necessary for the 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 anesthesiology with subspecialty certification in pain management 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: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested immune cell function assay lab tests for evaluation of her medical condition. Findings:  Two physician reviewers found that the immune cell function assay lab tests performed on the dates of service in dispute were likely to be more effective for this patient than other available options. The patient is status post bilateral lung transplantation and is at risk for both post-transplant lung rejection and opportunistic infections resulting from immunosuppression. Immune status monitoring of transplant recipients assists in identifying patients at risk of acute rejection, infection, and cancer, which are important sources of morbidity and mortality in these patients. ImmuKnow, which measures adenosine triphosphate (ATP) release by blood cells in vitro after stimulation, provides an objective assessment of the cellular immune function of immunosuppressed patients (Rodrigo et al). There have been a number of studies in various transplant recipients, including liver, kidney, heart, pancreas, and lung, which have found differences in ATP levels between transplant patients who were stable, those who were infected, and those undergoing rejection. Moreover, ImmuKnow is used by many transplant centers to help monitor immune status and adjust immunosuppressive dosing regimens, in conjunction with tissue biopsies, therapeutic drug level monitoring, and other blood markers. Therefore, based on the peer-reviewed literature and medical evidence submitted the services at issue were likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-two year-old female with a history of constipation and rectal bleeding is requesting authorization and coverage for Zelnorm.  The patient has tried laxatives and fiber, but continues to be symptomatic. The patients physician indicates a trial of Zelnorm provided good results.Reviewers Findings.  The reviewing physician found that this patient has tried multiple other alternatives for her constipation without relief. It also appears that the patient has had a positive response to a trial of Zelnorm.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested chiropractic services for treatment of her sciatica and bilateral knee problems.  Findings:  The physician reviewer found that the scientific data does not support chiropractic care or massage as effective interventions for pain control. To date, there has been little research into the treatment of acute neck pain with chiropractic manipulation. In addition, Bronfort and colleagues concluded that there is inconclusive evidence supporting the long-term efficacy of spinal manipulation for any type of low back pain. Overall, the authors did not find spinal manipulation and mobilization to be superior to other conservative management. Consequently, they concluded that well designed studies are still needed in order to determine whether spinal manipulation and mobilization provides any clinical benefit in this patient population. This patient has undergone extensive spinal adjustment treatments and electrical stimulation therapy. As of the said date, however no significant, sustained benefit would have been anticipated with further treatment. The additional therapy was not medically necessary given that there is a paucity of proven benefit with long-term chiropractic manipulation treatments or electrical stimulation in the setting of chronic spinal pain or other musculoskeletal conditions. Further, the records do not support any specific, clinically relevant benefit that can be clearly attributed to the therapy at issue. For these reasons, no significant benefit would have been expected with chiropractic manipulation, extraspinal manipulation and electrical stimulation for this patient over an independent exercise program, relative rest, self-applied palliative modalities and pharmacotherapy during the time period under review. All told, the services at issue in this case have not been established to have been medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

 A 64-year-old male enrollee requested Sovaldi, Olysio and ribavirin for medical treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that based on the available documentation, this patient is a Child-Pugh B patient with 10 points and is decompensated. However, use of Sovaldi, Olysio and ribavirin in patients with decompensated disease should be withheld outside the context of a clinical trial until there is more evidence supporting treatment. There is a paucity of medical literature demonstrating the safety and efficacy in this population of patients. The patient could possibly develop worsening decompensation on treatment. Additionally, there is no data on improvement of overall or disease specific health outcomes with treatment. Consistent with these findings, the requested medication regimen of Sovaldi, Olysio and ribavirin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee requested acute psychiatric inpatient treatment services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that acute psychiatric inpatient treatment were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the goal of the hospitalization was to stabilize the patient prior to admission to a residential treatment center. The documented descriptions of his behavior demonstrate that the patient was compliant with his medications and he was not aggressive or suicidal. In sum, the patient did not meet the medical necessity for inpatient level of care.  He was not at risk of harming himself or others and was not demonstrating severe behavioral problems. Thus, the services were not medically necessary and the patient was stable for transfer to a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Testopel 75 mg and prospective authorization and coverage for Testopel 75 mg, quantity of 12.Findings:  Two of the three physician reviewers found Low testosterone can lead to complications such as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. Testopel slowly releases testosterone over the course of three to six months. The medical evidence supports the medication at issue in this clinical setting. Therefore, the medication at issue was and is likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 24-year-old male enrollee has requested Adderall XR 20 mg per day for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. In the psychiatric practice the standard of care indicates that a patient returning for treatment of adolescent ADHD must be completely re-evaluated. According to the documentation submitted for review, there are no recent evaluations provided, either in-Plan or with the treating psychiatrist, that demonstrates the patient still meets the criteria for ADHD. In addition, this patient has many co-morbid diagnoses, including depression, substance abuse and anxiety. All of these co-morbid conditions can cause problems with attention and concentration. Given the absence of testing to validate the patients diagnosis, such as Conners CPT testing or a psychological evaluation the medical necessity of the requested medication has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys for treatment of his centralized intractable pain. The physician reviewer found that subsys is not medically necessary for treatment of the patients medical condition. Current standard of care for chronic pain associated is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In the retrospective study by Baron and McDonald, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Furthermore, prolonged use of high dose opiates might induce tolerance and abnormal pain sensitivity. Therefore, the patients request for Subsys is not medically necessary. 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 anesthesiology with sub-specialty certification in pain 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: Upheld

The patient is a 50-year-old female with ADHD and general anxiety disorder. The patients psychiatrist has proposed treatment of her general anxiety disorder with Provigil out of concern that treatment with stimulants will worsen her severe initial insomnia as well as exacerbate her general anxiety disorder. She has not been treated with antidepressants. The patient was prescribed Provigil 100mg twice daily and found that she was feeling better than I ever have, noting that her writing is better and I can concentrate a lot more. The patients intake evaluation notes she scored high on the following items: insomnia, guilt/self-blame, poor concentration, poor memory, affective instability, boredom, conduct problems, short attention span, general anxiety, incest history, chaotic relationships, headaches, irritable bowel, and TMJ. The patients provider has recommended the patient continue on Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Based upon the submitted documentation, it is not clear the patient has ADHD, though there appears to be more than enough evidence to suggest that she has depression and anxiety. Furthermore, it seems presumptive to assume that her initial insomnia will necessarily be worsened with daytime stimulants, clearly the mainstay treatment for ADHD. There is no evidence the patient was actually tried on a stimulant. Moreover, given the patients depressive symptoms, it seems a proper course of an antidepressant for depression per se, or perhaps a course of atomoxetine would be in order. Finally, there is not yet a single, double-blinded study to support Provigil as a treatment for ADHD.  For these reasons, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.