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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. The submitted documentation does not support the medical necessity of the requested services. A large randomized controlled trial examining the effect of adding acupuncture or Alexander Technique exercises to usual care (medication and physical therapy) for chronic neck pain found significant improvements in pain reduction and associated disability and self-efficacy. Regarding the complaints of vertigo-dizziness, acupuncture demonstrates a significant immediate effect in reducing discomforts and visual analog scale of both dizziness and vertigo.Although an acupuncture trial for pain management would have been reasonable and supported by the peer review literature, additional treatments should only occur based on progressively greater, incremental objective gains. In reviewing the submitted records, it appears that the patient underwent an unknown number of acupuncture sessions for the treatment of vertigo and cervical myofasciitis. The provider failed to document the number of sessions completed and/or any specific, measurable, sustained, significant, objective functional improvement (quantifiable response to treatment) obtained with previous acupuncture. Based on the records, the patient is not presenting with a flare-up of the condition or a re-injury. Under these circumstances, additional acupuncture treatment is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is licensed in oriental 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

The patient has requested authorization and coverage for a Toujeo Max U-300 Solostar 300 units/mL insulin pen. Kumar and colleagues note that insulin therapy remains the cornerstone of effective diabetes management, and that timely intensification of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications. Borgono and Zinman report that the continued development of improved injectable insulin formulations with superior pharmacokinetics and pharmacodynamics enhances glucose control and represents important clinical advances in the treatment of both type 1 and type 2 diabetes. Brown and colleagues report that Toujeo insulin glargine U-300 (Gla-300) is a new option for the treatment of diabetes mellitus that has been shown to be effective, with fewer episodes of hypoglycemia and slightly less weight gain than prior insulin therapies. In this case, the submitted records document that the patient is doing well on Toujeo insulin and that her glycemic control has gradually improved. In this clinical setting, the requested medication is medically indicated. Therefore, a Toujeo Max U-300 Solostar 300 units/mL insulin pen is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 4-year-old female enrollee has requested  speech therapy (at 2 hours per week); and occupational therapy (at 2 hours per week) for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). This patient has identified fine motor and adaptive skill deficits. Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. Occupational therapy at a frequency of 2 hours per week is medically necessary and appropriate for this patient with deficits in fine-motor and adaptive skills.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Traditional systemic therapies for psoriasis have a well-documented array of toxicities. Otezla is an oral PDE4 inhibitor, which provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Otezla has been widely studied for this indication. The provider documented the patient has been treated with Otezla with good results and no side effects. Given this patients history and presentation, the requested Otezla is medically necessary for treatment of this patients chronic plaque psoriasis.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xarelto. This patient has severe multi-territory vascular disease with prior cardiovascular, lower extremity vascular disease and brainstem stroke. Given the extensive vascular disease, he is at risk for recurrence of ischemic disease in both the cardiovascular and peripheral vascular systems. The use of lower dose Xarelto has been shown to decrease the recurrence of vascular events in individuals with this type of medical history. This therapy may be more effective in individuals with extensive disease who are at very high risk for recurrent vascular events, like this patient. The current medical evidence supports the requested medication in this clinical setting. Therefore, Xarelto 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 internal medicine with sub-specialty certification in cardiovascular disease 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 55-year-old female enrollee has requested the LINX procedure for treatment of her gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Jobe and colleagues noted that in prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. The authors concluded that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. The medical records do not demonstrate the patients daytime and nocturnal sense of regurgitation is entirely due to GERD. Testing revealed an infrequency of correlation of reflux episodes with symptoms and her DeMeester scores remained normal for the 48-hour duration of pH testing. Moreover, the patient has not undergone pre-operative assessment including motility studies. Given the lack of support for the requested procedure, the LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework the patient met the criteria for the RTC services. The patients composite score is consistent with medically monitored residence based services. Given these findings, the RTC services were medically necessary for the patient.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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested a continuous passive motion (CPM) device for the treatment of her condition. Findings:  The physician reviewer found that the CPM device is used routinely postoperatively following knee replacement surgery. It has been used extensively for more than twenty years. The equipment is used for one to two weeks postoperatively, and it is sometimes used for knee procedures other than total knee replacement. The CPM device was medically indicated and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested botulinum toxin (Botox) injections for treatment of her medical condition.  Three physician reviewers found that based on the documentation submitted for review, the patient has had significant headache freedom from previous Botox injections. After her initial worsening, Botox was effective in treating the patients chronic headache disorder. There is a typical latency prior to the establishment of efficacy when Botox is used under these circumstances. Furthermore, there is data supporting efficacy of Botox used for chronic daily headache in the peer-reviewed literature cited above. In this case, botulinum toxin (Botox) injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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:   All three reviewers are board certified in neurology 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: The parent of an enrollee has requested authorization and coverage for PediaSure Enteral Formula. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested formula. The patients parent reported that the patient has food aversions. However, there is a lack of documentation from a medical provider indicating that the patient does not eat well. The medical documentation does not support that the patient needs PediaSure Enteral Formula. The records do not document failure to thrive, and there is no documentation of other treatments tried and failed. Thus, PediaSure Enteral Formula is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested formula is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus infection 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. The patient should be considered treatment-naive according to guidelines because she failed interferon, but not PEG-interferon and ribavirin. The guidelines recommend that treatment-naive genotype 1b 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 (Kowdley, et al; Afdhal, et al). The AASLD/IDSA recommendation is the same even if the patient was considered treatment-experienced with PEG-interferon/ribavirin. All told, the requested treatment with Harvoni 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

A 43-year-old female has requested a Synvisc One injection for treatment of her left hip osteoarthritis.  Findings:  The physician reviewer found that although the benefits of viscosupplementation have been generally accepted in the treatment of osteoarthritis of the knee, there is less agreement with its use in the hip (van den Bekerom, et al). Some studies have been encouraging, but have also noted the need for further prospective, randomized, placebo-controlled studies before definite conclusions can be drawn. In the absence of placebo-controlled studies, the efficacy of hyaluronan injections cannot be conclusively determined (Conrozier and Vignon). Larger, placebo-controlled trials are needed to confirm the efficacy of viscosupplementation in hip osteoarthritis (Abate, et al). In addition, prospective controlled trials are needed to confirm the safety and efficacy of hyaluronic acid in the treatment of hip osteoarthritis, and rigorously designed studies are necessary, since the use of hyaluronic acid as a treatment for osteoarthritis of the hip is not based on large randomized controlled trials (Colen, et al). For these reasons, the requested therapy has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested  kyphoplasty for treatment of her vertebral fractures. Findings:  The physician reviewer found that the patient suffered with compression fractures and attempted conservative treatment without success. After the failure of these measures, kyphoplasty was recommended. Kyphoplasty is a standard means of treating fractures of the vertebrae in patients with persistent pain. Kyphoplasty has been well studied and has been approved by the Food and Drug Administration. The procedure was necessary to alleviate the patients pain and was clearly successful in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar Gel. The U.S. Food and Drug Administration (FDA) approves the use of H.P. Acthar for the treatment of rheumatic disorders as an adjunctive therapy for short-term administration, to tide the patient over an acute episode or exacerbation of rheumatoid arthritis (RA). However, there is a lack of current medical literature supporting the use of  Acthar or repository corticotropin injections (RCI) for the treatment of RA. In a study of eight patients, Gillis and colleagues concluded that while RCI could be an effective add-on therapy for patients who have exhausted several classes of treatments, larger clinical trials were necessary to further confirm the efficacy of RCI in patients with refractory RA. Singh and colleagues note that the American College of Rheumatology guideline for the treatment of RA recommends methotrexate and a tumor necrosis factor inhibitor (TNFi) in patients who have failed DMARD monotherapy. In patients with active RA who had previously received treatment with one or more TNFi therapies, Smolen and colleagues assessed the efficacy and safety of a second TNFi, golimumab, and found that golimumab reduced the signs and symptoms of RA. In this case, the patient has a history of seronegative rheumatoid arthritis (RA). While the records note the patient has tried and failed multiple therapies, they fail to demonstrate an acute exacerbation of RA. Given the current medical literature, the requested medication is not medically indicated. Therefore, H.P. Acthar Gel 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 rheumatology 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 thirty-four year-old suicidal female is requesting for reimbursement for acute inpatient psychiatric services.  Reviewers Findings:The reviewing physician found that the patient has a complex set of diagnoses in addition to her underlying depression and a strong family history of bipolar disorder.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female who has a diagnosis of a major depression with refractive symptoms of sleepiness and lethargy.  She has been seen in continuing therapy since October 1998.  Prior to starting samples of Provigil she was prescribed Lamictal, Anafranil and Wellbutrin.  Her provider gave her samples of Provigil from May 2005 through October 2005.  The progress note on December 2005 states that the patient reported: I can tell the difference. The use of stimulant medication was suggested by the psychiatrist but the patient refused such for fear of the addiction potential.  The patient continues to have symptoms of lethargy and sleepiness without the use of Provigil.  The patient has requested authorization and coverage for Provigil.  The Health Plan denied her request based upon a determination that the medication is not medically necessary.The provider does feel that the patient has had short-term improvement in her Major Depressive Disorder (MDD) with the samples of Provigil that he supplied to her.  Her subjective report of improvement is consistent with the results described in the literature for the initial three months of treatment with Provigil. However, there is no evidence in the literature that the long-term use of Provigil for treatment of MDD is efficacious.  There is also support in the literature for the use of a stimulant medication for the symptoms described with this patient, as an alternative to Provigil.  Such use, when prescribed by a psychiatrist, does not increase the possibility of dependency on amphetamines as the patient fears. These fears can be addressed in the patient-therapist relationship. The use of stimulant medication for the augmentation of other medications in the treatment of depression is approved by the FDA and is considered efficacious. This approach has few aversive side effects and continues to remove symptoms over a period of time beyond 80 days.  Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.