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

The patient is a 50-year-old female who initially presented to her doctor with urinary incontinence. She was treated with anticholinergics, Detrol and Imipramine and underwent a bladder neck suspension in July 2004.   The surgery resolved her stress incontinence but her urgency persisted. Repeat urodynamic studies suggested that the patient still had an element of bladder instability with uninhibited contractions. She was again treated with Vesicare and Detrol, which were not completely effective.  In addition, the patient was involved in a bus accident resulting in a disc herniation at C6. Discotomy with bone grafting was recommended for treatment of the back injury. The patient noted that since the accident her bladder symptoms have been worse. Her provider recommended Botox injections into the base of the bladder to reduce the unstable bladder contractions. The patients request for authorization was denied by the Health Plan based upon a determination that the requested therapy is not medically necessary.Botox bladder injections to reduce instability remain an interesting but investigational use of the drug. The therapy is not yet a commonly accepted medical practice and the manufacturer is currently conducting investigational studies to determine the efficacy of this treatment for bladder instability with urgency incontinence. Additionally, the patient had a spinal disc injury this year, which she states has exacerbated her bladder problems and she awaits corrective spinal surgery. It is possible her bladder symptoms may improve when the neurological problem is treated.   Based upon the information set forth above, 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: Overturned

The parent of an eight-year-old male enrollee has requested continued cognitive behavioral therapy utilizing applied behavioral analysis techniques for treatment of the enrollees autism.  Findings:  The physician reviewer found that on review, the patients treatment plan documents baseline behaviors as well as goals and a timeline for achievement. These goals focus on verbal and non-verbal communication, gross motor imitation, self-help skills, dressing, potty training, proper eating habits, social interactions, interactive play, vocal initiation, and on-task behavior. Though the treatment plan includes functional skills that may also be addressed in the IEP, these skills are necessary to perform daily functional activities. As such, the patient should also have these issues treated during the requested 15 hours per week of cognitive behavior therapy utilizing the ABA approaches referenced above. Therefore, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female has requested coverage for a WalkAide functional electrical stimulator for treatment of her drop foot secondary to multiple sclerosis.  Findings:  Three physician reviewers found that the patient was diagnosed with multiple sclerosis nine years ago and has been experiencing problems with foot drop. She reports that she now has trouble walking and has experienced frequent falls. She currently uses a walker, even in the home. The patient has undergone physical therapy and has worn an over the counter brace. The patients provider reports the patient has an unsafe and inefficient gait pattern due to her foot drop and that the use of an ankle foot orthosis (AFO) has been unsuccessful in treating her foot drop. The provider recommended the WalkAide functional electrical stimulator. The patient states a one month trial with the WalkAide device resulted in significantly fewer falls. The literature regarding the WalkAide functional electrical stimulator in multiple sclerosis patients is not definitive. There is more support in the literature for the WalkAide functional electrical stimulator in patients after stroke, however, the spasticity and foot drop issues after stroke are analogous to those in patients with multiple sclerosis. Many aspects of the literature for foot drop in post-stroke patients can be extrapolated to patients with multiple sclerosis. In this patients case, she did not appreciate sufficient benefit from a standard AFO, as her mobility and activities of daily living were still very limited. It appears that her spasticity issues limit her functional improvement from a standard AFO. The one month trial of the WalkAide functional electrical stimulator provided greater mobility and improvement in the patients activities of daily living. Her gait stability, gait speed and walking pattern were noted to improve with the WalkAide functional electrical stimulator versus the standard AFO. As such, the patient did show sufficient improvement during the trial period to support the use of the device in this particular case.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested a robotic-assisted prostectomy for treatment of his prostate cancer. Findings:  The physician reviewer found that radical prostatectomy is a good option for treatment of this patients condition. Laparoscopic radical prostatectomy has a similar oncologic outcome and probable lower morbidity compared to conventional open radical prostatectomy. There are no documented advantages to robotic assisted prostatectomy. This patient is a good candidate for a traditional laparoscopic radical prostatectomy and there is no evidence demonstrating he would have a better outcome with robotic assisted prostatectomy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in the knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate 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 options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty for mild to moderate osteoarthritis. Thus, the requested Euflexxa injection series in the knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for services provided at a medical center. Cecconi and colleagues noted that, The World Health Assembly and WHO made sepsis a global health priority in 2017 and have adopted a resolution to improve the prevention, diagnosis, and management of sepsis. In 2016, a new definition of sepsis (Sepsis-3) was developed. Sepsis is now defined as infection with organ dysfunction. The patients blood culture reportedly showed gram-positive cocci as an outpatient, and was started on antibiotics. However, the patient did not require admission for management of her symptoms. The patient did not have documented evidence of sepsis when hospitalized (Iwashyna, et al.). A full admission for sepsis requires evidence of serious infection with report of signs or symptoms such as high fever, impaired renal function, and confusion. The patient had none of the expected corollaries of sepsis. Therefore, the services at issue were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 60-year-old female who sustained a left radial neck fracture in March 2003.  She was treated by an orthopedic surgeon and referred for physical therapy (PT) after her splint was removed one month later. The patient made good progress with PT and Dynasplint therapy was initiated in April 2003 and continued through July 2003. The patients request for reimbursement for the cost of the Dynasplint therapy was denied by the Health Plan based upon a determination that the therapy was not medially necessary.The clinical information submitted provides no explanation as to why Dynasplint therapy was initiated and there are no physician records documenting the need for this therapy. The patients physical therapist noted the patient was making good progress from the beginning of her PT program. In April 2003 the therapist indicated the patient would be fitted for a Dynasplint; however the PT progress notes do not explain why the therapy was required in light of the patients consistent progress. As such, the available records do not contain sufficient information to substantiate the medical basis for the Dynasplint therapy. Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for allogenic islet cell transplant. The literature comparing islet cell transplantation to pancreas transplant demonstrates that islet cell transplantation is associated with excellent long-term results. Studies found that pancreatic islet cell transplant has moved from a curiosity to a realistic treatment option for selected patients with type 1 diabetes mellitus with hypoglycemic unawareness. This patient has a longstanding history of diabetes with episodic symptomatic hypoglycemia. The requested islet cell transplant is a next reasonable step in treatment for this patient, especially since he is on immunosuppressive therapy and is status post two prior pancreas transplants. Given these findings, the requested allogenic islet cell transplantation is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested allogenic islet cell transplantation is 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 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 surgery 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter mitral valve repair (MitraClip procedure). This patient presents with transposition of the great arteries status post balloon atrial septostomy, Blalock-Taussig shunt, bidirectional Glenn shunt, and completion of hemi-mustard operation. A recent transthoracic echocardiogram reportedly demonstrated severe dilation of the right ventricle and a severely decreased systolic function. The patients provider has recommended transcatheter mitral valve repair with MitraClip. Based on current peer-reviewed medical literature, the requested MitraClip procedure is likely to be more beneficial for treatment of the patient than any available therapy. There are ample data demonstrating that the MitraClip procedure is safe and effective in this patients clinical scenario (Nickenig, et al.). In this case, the patient has complex congenital heart disease. He has undergone previous cardiothoracic surgical procedures and he is an unacceptably high surgical risk. The MitraClip is a transcatheter procedure recommended as a safer option to correct this patients tricuspid regurgitation, as he has with severe valve disease, advanced heart failure symptoms, and limited options for treatment. Therefore, the requested transcatheter mitral valve repair (MitraClip procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested transcatheter mitral valve repair (MitraClip procedure) is 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 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 49-year-old male enrollee has requested the UCSF Weight Loss Clinics physician supervised Very Low Calorie Diet program for the treatment of his obesity.  Findings:  The physician reviewer found that this patient is at high risk for diabetes mellitus and also has risk factors for cardiovascular disease. The existing comorbidities point to an urgent need for weight loss. However, it is not clear from the record provided what formal treatment he has undergone in recent years. Consultation with a registered dietician is the usual first-line approach for weight loss in patients such as this one. The Diabetes Prevention Program study demonstrated the benefits of lifestyle interventions for inducing weight loss and preventing the onset of type 2 diabetes in high-risk patients. Furthermore, the benefits of very low calorie diets are not clear. Although popular several years ago, they are now rarely used to treat obesity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is 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 physician 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 parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that based on review of the available records, this patient has severe delay in receptive and expressive language with a history of autism. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. A meta-analysis by Law and colleagues reported on the positive effects of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. In the case of this patient, the most recent speech and language evaluation available documents severe language delay. Therefore, based on the medical literature, speech therapy is medically necessary for this patient with autism and severe language delay. A current speech and language evaluation should be performed at the time the speech therapy is initiated to assist in monitoring the patients progress.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested chelation therapy for the treatment of his lead toxicity. Findings:  Three physician reviewers found that the diagnosis of lead toxicity is made based upon a combination of signs and symptoms as well as elevated blood lead levels. There is not uniformity in laboratory reference values for heavy metals in urine. It is not always clear at what levels damage can occur. Per the National Institute for Occupational Safety and Health, the units in which these substances are reported can vary, and it is difficult to draw comparisons between laboratories. Heavy metal testing can vary in levels depending upon the body substance tested. For instance, venous blood levels are more appropriate for measuring lead, whereas urine levels are more helpful for mercury.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested radiofrequency neurolysis for treatment of her sacroiliac joint pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis has been reported in the peer-reviewed medical literature as a treatment option for patients with a diagnosis of SI joint pain who have failed conservative treatment. There is a lack of documentation of specific SI joint pain on examination. In addition, the providers notes do not include a targeted history, physical examination, and treatment plan to support an indication for the requested radiofrequency neurolysis. Thus, the requested services are not likely to provide this patient with greater benefit for treatment of her medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested the prescription drug Skelaxin for the treatment of her musculoskeletal condition. Findings:  The physician reviewer found that the Health Plan has recommended the patient attempt trials of two formulary alternative muscle relaxants prior to authorization of Skelaxin. This is a reasonable position. There is no clinical evidence demonstrating that the patient must take Skelaxin or that the muscle relaxants recommended by the Health Plan are contraindicated. Based upon the information provided, it is likely that the patient will benefit from the muscle relaxants recommended by the Health Plan. If the patient fails reasonable trials of two of the recommended muscle relaxants the Health Plan should authorize Skelaxin. However, there is currently no medical justification for authorizing Skelaxin.