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

A 23-year-old male has requested monthly intramuscular injections of Invega Sustenna 156mg, two weeks following a loading dose of Invega Sustenna 234mg for treatment of his schizoaffective disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The effectiveness of a particular antipsychotic varies according to clinical circumstances.  Treatment with antipsychotic medication is indicated, as schizoaffective disorder is a chronic illness with far-reaching functional deterioration.  Often, multiple medication trials are common in this patient population.  In this clinical setting, effective treatment has to be individualized.  The treating team has recommended intramuscular injections of Invega Sustenna after multiple antipsychotic and mood stabilizing medication trials.  In this case, the requested medication is medically appropriate and consistent with good medical practice.  All told, monthly intramuscular injections of Invega Sustenna 156mg, two weeks following a loading dose of Invega Sustenna 234mg are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested an F-18 sodium fluoride positron emission tomography/computed tomography (PET/CT) scan for evaluation of his bladder cancer.   Findings:  Three physician reviewers found that there is sufficient medical literature supporting the use of an F-18 sodium fluoride PET/CT scan in this clinical setting. The requested service has been demonstrated to identify both local and distant spread of bladder cancer with success. The requested diagnostic study has utility for staging in bladder cancer and in staging locally extensive lesions. In addition, it can help identify lymph node and distant metastases and help in differentiating recurrent disease from tissue changes following radiation. Thus, the use of the requested F-18 sodium fluoride PET/CT scan is considered appropriate in order to stage the disease and evaluate the response of the disease to treatment. Therefore, based on the peer-reviewed literature and medical evidence submitted the requested service is likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Gel One injections. Findings:  The physician reviewer found that Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has few available treatment options. The patient complains of severe chronic bilateral knee pain that has failed to respond to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and bilateral corticosteroid injections. Furthermore, she is not a candidate for total knee arthroplasties due to the x-ray evidence of mild osteoarthritis. Given these findings, the requested bilateral Gel-One injections are medically necessary for 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: Urgent Care
Decision: Upheld

A 38-year-old female enrollee has requested for emergency ambulance services. Findings:  The physician reviewer found that her illness level of severity was described as mild. No medications were administered. In the Emergency Department, the patient was found to have normal blood tests. She was given intravenous fluids and an antiemetic and discharged. The purpose of ambulance services are not to provide transportation, but rather to provide a safe method of transporting patients who require stabilization or treatment en route to the Emergency Department. This patient did not require any medical intervention during her transport. She did not require services that only a fully equipped ambulance can provide. This patient could have been safely transported by means other than ambulance. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection to the left knee. 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 osteoarthritis of the left knee. 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, a Monovisc injection to the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee requested sclerotherapy for medical treatment of his symptomatic varicosities.  Findings:  Two physician reviewers found that the patient has small varicose veins with no underlying reflux or severe symptoms. His symptoms are atypical for venous disease. The records do not demonstrate that the patient has completed an adequate course of conservative stocking use. In addition, there is a lack of clinical findings indicating that treatment with sclerotherapy of the small varicose veins will improve the patients symptoms. Accordingly, the sclerotherapy at issue was not and is not likely to provide this patient with a greater benefit than standard available interventions.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested percutaneous tibial nerve stimulation for the treatment of her urinary frequency. Findings:  Three physician reviewers found that percutaneous tibial nerve stimulation has been proposed as a form of minimally invasive neuromodulation to attempt to impact the bladder symptoms of frequency, urgency, as well as pelvic pain syndromes (Van Balken and colleagues 2003). The difficulty of defining exactly what pathology is being addressed is the first challenge in patients with varieties of pelvic voiding and pain syndromes. The studies involve small numbers of patients treated for short periods of time, up to 12 weeks. Some symptomatic improvement and subjective relief is reported though no treatment was effective in actually eliminating detrusor instability when that variable was addressed (Vandonick and colleagues). There is no long-term data and indeed, some of the early studies suggest the treatments must be continued for the effects such as they are to be durable (Van der Pal and colleagues). The optimal candidates and conditions for percutaneous tibial nerve stimulation as far as duration and number of treatments, and duration and durability of response need to be clarified by additional studies. Virtually all of the current studies are short-term with subjective self-reporting being the main criteria of success.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 26-year-old female enrollee has requested hospital services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the medical records reveal that the patient was no longer an imminent threat to herself or others. There is no evidence that she required 24-hour supervision/observation or that she had a medical condition that required the resources of an acute hospital. The patient had stabilized and progressed to a point were she could have been safely and effectively treated at a less intensive level of care. The patient had some insight into her condition and was cooperative with treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old male with a history of vitreous floaters and blurred vision. To treat this condition the patient decided to proceed with a Yag procedure, which was performed on two separate occasions in June 2005.  The Health Plan did not authorize this procedure and has denied reimbursement. The Health Plan recommended a closed vitrectomy for the patient.Vitreous floaters are a common problem where treatment is rarely advised as all available treatments have significant risks. Both the Yag procedure and the closed vitrectomy have the potential risk of retinal detachment. Closed vitrectomy results in an increase in cataract formation while it is unknown how much of an increase in cataract formation results from a Yag procedure. Furthermore, laser therapy such as the Yag procedure often results in a large opacity converting to numerous small opacities. Moreover, treatment of any type is not considered standard of care for vitreous floaters.Based upon the risks and variable efficacy of the procedure at issue, I have determined the procedure at issue was not medically necessary for treatment of the patients condition. Therefore, the Heath Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Pulmicort Respules for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is a lack of documentation submitted for review establishing the medical necessity for Pulmicort Respules in this clinical setting. Nebulization provides a useful alternative mode for delivery of corticosteroids that are available as a nebulizing suspension (beclomethasone and budesonide) in situations where a metered dose inhaler (MDI) or dry powder inhaler (DPI) device may not be suitable. Situations where budesonide inhalation suspension (Pulmicort Respules) would prove useful include in children up to five years of age (approved up to eight years of age in the US), patients greater than five years of age who experience difficulty using MDIs or DPIs or patients of any age who cannot coordinate or activate a MDI or DPI because of dyspnea (Thorsson and Geller). In this case, there is a lack of documentation showing that a MDI or DPI device is not suitable for use, demonstration of a poor technique/coordination with MDI or DPI device, previous or current inability to use MDI or DPI device, or history of local side effects from use of MDI or DPI device. The patient has documentation of current use of the MDI device, Qvar. All told, Pulmicort Respules have not been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in pediatrics and allergy and immunology 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: An enrollee has requested authorization and coverage for Otezla 30 mg tablets, 60 per 30 days. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has tried and failed therapy with topical steroids and excimer laser.  She reports a needle phobia, making the injectable biologics a poor option for therapy.  The Health Plan guidelines indicate that Otezla may be a covered benefit after failure or contraindication to treatment with methotrexate, acitretin or cyclosporine.  The provider noted that methotrexate cannot be used as the patient is of childbearing potential.  However, the potential for childbearing is not an acceptable contraindication.  There are no definite contraindications (such as current pregnancy, transaminitis, or active hepatitis) to methotrexate therapy, and there has not been a treatment failure with the medication. Therefore, Otezla 30 mg tablets, 60 per 30 days is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the patient has plaque psoriasis who has tried and failed therapy with topical steroids. However, there is no documentation as to a treatment trial or intolerance to any of the systemic formulary medications, including methotrexate, cyclosporine, Enbrel or Humira. As there has been no prior treatment with the preferred formulary agents, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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

A 47-year-old male enrollee has requested 30 intermittent uses of catheters per month and 30 indwelling catheters per month for treatment of his paraplegia and spastic neurogenic bladder.  Findings:  The physician reviewer found that this patient is documented to have a neurogenic bladder and the treating provider reports that the patient is not able to clean the catheters used for intermittent catheterization. The justification for the clean method assumes a patient has the functional ability to wash and clean the catheters, which is not an accurate description of this patients clinical scenario. Although many paraplegic patients are able to employ the clean technique for reuse of intermittent catheters, this patient has difficulty leaning over a faucet due to his spinal injury and brain damage. In addition to his impairment, this patient continues to work, which complicates his circumstances even further as he is away from home in a public restroom. However, this patients medical records do not provide sufficient documentation to establish the medical necessity for the requested indwelling catheters. The number of sterile catheters required per month should therefore be increased to replace the number of requested indwelling catheters. As such, the patients request for additional catheters should be approved with a maximum of 60 intermittent catheters per month based upon his functional status.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested chemiluminescent assay (82397), immunoassay for analyte other than infectious agent (83520), immunofluorescent study (88347), gammaglobulin IGA, IGD, IGG, IGM, each (82784), molecular diagnostics HP nuclear acid each type (83891), molecular diagnostics, amplification, target, multiplex (83900), molecular diagnostics, nucleic acid probe each (83896) and molecular diagnostics, interpretation and report (83912) for evaluation of his diarrhea.  Findings:  Two physician reviewers found that the history, presentation, and available diagnostic tests are not supportive of Crohns disease.  Moreover, the gold standard for the diagnosis of Crohns disease is based on histologic findings. The accuracy and predictive value of antibody tests for the diagnosis of inflammatory bowel disease continue to be elucidated. Serologic tests are best performed as an adjunct to the diagnosis of inflammatory bowel disease, and are mainly performed to differentiate between Crohns disease and ulcerative colitis and predict their course.  In this case, the use of serologic tests is not backed by the available diagnostic data.  The medical records do not support the diagnosis of inflammatory bowel disease. Based upon the submitted documentation, the requested testing is not likely to be superior over other tools for evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the residential treatment center (RTC) services. This patient has a long history of eating disorder and outpatient treatment was not consistently effective in stabilizing the symptoms. She was admitted to RTC. She has exhibited symptoms of restricting, calorie counting, compulsively exercising, diet pills, laxatives, diuretics, food rituals and weight loss which were not being effectively managed in outpatient services and thus higher level of care was medically necessary. Per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders range from intensive inpatient settings to residential and partial hospitalization programs to varying levels of outpatient care. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this choice. Based on the review of the records, the services provided were medically necessary for this patient in order to allow for sufficient time for treatment with integration of the strategies learned during treatment and for effective discharge planning to reduce the chances of relapse. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dopamine transport scan (DatTscan) (SPECT scan) for evaluation of the enrollees essential tremor versus Parkinsons diseaseFindings:  Two physician reviewers found that while one study is not indicated for all patients with essential tremor, it has been shown to be useful in cases where the diagnosis of essential tremor and Parkinsons disease are both being considered and cannot be differentiated based on clinical grounds. There is sufficient peer-reviewed literature supporting the use of the study in differentiating cases of Parkinsons disease and essential tremor. It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are different and the treatments for Parkinsons disease can have significant side effects. In this clinical setting, both essential tremor and Parkinsons disease conditions were being considered and the patients diagnosis was aided by the use of the study results.  Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in neurology 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.