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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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.  Per the guidelines, treatment-naive, non-cirrhotic, genotype 1a patients should be treated with Harvoni for 12 weeks, or with Viekira Pak and ribavirin for 12 weeks.  Although treatment of hepatitis C is necessary, the information supplied in this case does not provide justification to support coverage of Harvoni over Viekira/ribavirin. No head-to-head clinical trials have compared these medications, and the patient does not have anemia, pregnancy, or other contraindications to ribavirin.  No clear contraindication to ribavirin is presented in this case.  For these reasons, the requested treatment with Harvoni for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection.  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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Rasuvo 25 mg/0.5 mL injected weekly. For patients with uncontrolled rheumatoid arthritis symptoms despite taking oral methotrexate, the American College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis recommends switching to subcutaneous methotrexate over the addition of or switching to alternative disease-modifying antirheumatic drugs (DMARDs). Senbel and colleagues report that changing from oral to subcutaneous route may improve adherence, control of rheumatoid arthritis, and quality of life even in patients with an unchanged methotrexate dose. When administered subcutaneously, the bioavailability and efficacy of methotrexate is improved as it bypasses the requirement for active gastrointestinal absorption of the drug as required when administered orally. In this case, the records indicate that the patient has failed to respond to oral methotrexate. The patient also reports a severe needle phobia and has been tolerating Rasuvo auto-injector pen therapy without an exacerbation of anxiety related to a needle phobia. In this clinical setting, given the patients failure to respond to oral methotrexate tablets, the requested medication is medically indicated. Therefore, Rasuvo 25 mg/0.5 mL injected weekly 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.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested Botox injections for the treatment of his myofascial back pain. Findings:  Two physician reviewers found that although Botox is certainly not a first-line therapy for back pain, there is sufficient medical literature that demonstrates its benefit in select populations. Although underpowered, the Lew study reported benefit in SF-36 scores compared to controls. This particular patient has failed multiple standard therapies and has shown some benefit to trigger point injections, thus further suggesting the benefit of Botox. A trial of Botox with a repeat assessment after treatment to evaluate response and determine future course of treatment should be granted.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions (See Unique Patient Populations).  Moreover, the recommendation for treatment-naive chronic HCV patients with genotype 1a is daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. Based on the clinical documentation submitted for review and treatment guidelines, the requested medication is medically necessary for treatment of the patients HCV.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for Acessa ablation minimally invasive procedure. Findings:  The physician reviewer found that surgical options for uterine preservation in the treatment of fibroids include myomectomy, uterine artery embolization, magnetic resonance imaging (MRI) guided focused ultrasound surgery and radiofrequency ablation. The Acessa procedure uses radiofrequency ablation, which targets the fibroids, with the goal of decreasing secondary affects to the organs adjacent to the uterus which share the same blood supply. There are currently insufficient data in the peer-reviewed literature to adequately assess the Acessa procedure. Final Result: The reviewers determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in obstetrics and gynecology 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 reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the services at issue in this clinical setting. In this case, the patients alcohol use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. His drinking was straining his marriage and undermined the recovery environment at home.  His excessive consumption was jeopardizing his employment. Although he was not diagnosed with a psychiatric illness, the patient was negotiating emotional dysregulation stemming from intrapsychic stress and substance use. Finally, despite completion of a residential treatment program during the episode of illness, the patient was unable to maintain sobriety in his environment.  Based on the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting during the dates of service in dispute and was likely to have relapsed in a community-based setting if discharged during this timeframe. In this patients case, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness.  In sum, residential treatment was medically necessary for the treatment of this patient. Fulfills requirements of (1374.33)(h)(1)(H) and (K)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. Fulfills requirement of 1374.33(h)(1)(I)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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for methylphenidate (5 mg/5 mL, which equals 20 mg, four times daily). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients attention-deficit/hyperactivity disorder (ADHD). The submitted documentation does not support the medical necessity of the requested medication regimen. The medication dosage requested exceeds the U.S. Food and Drug Administration maximum allowed for adolescents. The progress notes indicated that the patient has tried and failed several medications with some resulting in side effects. There are multiple treatment options available for adolescents with attention-deficit/hyperactivity disorder. The records do not indicate whether the patient has been adherent to past medication regimens. It is not clear whether the patient has undergone psychotherapy to help decrease some of the patients symptoms or help with organizational skills. The exact length of previous medication trials was not indicated in the records. There is a lack of support for the requested medication regimen in this clinical setting. In summary, methylphenidate (5 mg/5 mL, which equals 20 mg, 4 times daily) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 psychiatry with sub-specialty 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: Upheld

A 22-year-old female enrollee has requested weekly individual psychotherapy services for treatment of her major depression.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients with major depressive disorder.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which weekly or even twice-weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In this patients case, the submitted documentation does not support the medical necessity of the services at issue.  In a letter, the provider noted that the patient has made progress and treatment duration is indeterminate.  A comprehensive treatment plan was not provided. Information such as developmental history, treatment history, quantifiable goals, barriers to progress, multidisciplinary contributions, physical examination, and supportive community interventions are needed to determine if the increased frequency and duration of sessions are bolstering autonomy and resiliency while mobilizing the patient towards remission.  The Health Plan approved continued outpatient combined medication management/individual psychotherapy sessions at a frequency of once every two weeks from the said date forward.  The treatment frequency recommended by the Health Plan was medically appropriate.  All told, weekly individual psychotherapy services from the date in question forward were not and are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested Butalbital-Aspirin-Caffeine (Fiorinal) 50-325-40mg oral tab and Butorphanol (Stadol) 10 mg/ml nasal spray for treatment of her headaches.  Findings:  The physician reviewer found that Baron and colleagues report 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 this retrospective study, 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. Ballantyne and colleagues reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, it is in the patients best interest to wean off the requested medications. Therefore, the requested Stadol and Fiorinal are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Euflexxa injection series.Findings 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 chronic pain in both knees due to osteoarthritis. The records note a history of benefit from a series of prior injections completed in January 2021. The patient has not benefited from other conservative treatments, including physical therapy, and is not a candidate for total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injection series is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  Two of the three physician reviewers found that the an endoscopy showed a normal esophagus, a very small hiatal hernia, normal stomach, and normal duodenum. A 48-hour Bravo pH study showed elevated DeMeester score of 19.3. Per the provider note, the patient was having severe symptoms despite maximal medical therapy (including Prilosec and Nexium), behavioral changes, and dietary changes. His symptoms include reflux, severe and debilitating episodes of coughing, and regurgitation (but not dysphagia).  The patient has requested coverage for the LINX Reflux Management System.  The Health Plan has denied the requested services as investigational for treatment of the patients GERD. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. In the Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for skilled nursing facility services. The enrollee has also requested authorization and coverage for physical therapy, cognitive therapy, vocational therapy, and speech therapy for three to six months.Functional impairments due to traumatically acquired brain insults can improve with time through a natural recovery processes. These impairments are also generally amenable to rehabilitation interventions. Nevertheless, deficits can remain severe, particularly in the setting of severe injuries, resulting in protracted and profound functional deficits. There may be a limit to the benefits of rehabilitation interventions when impairments are severe. The efficacy of rehabilitation specifically aimed at improving cognitive deficits due to severe traumatic brain injury, moreover, is not established.In this case, the patient sustained a severe traumatic brain injury due to an assault, with additional cerebral insults that followed. The patient is noted to have undergone rehabilitation but has had persistent, profound functional deficits. Records show that the patient had limited active participation with therapies four months ago, and no significant progress. The patient continued to have significant cognitive, physical and functional deficits three months ago, and her capacity to actively participate in therapies and potential for progress were limited. There were no nursing, medical, physical therapy, occupational therapy, speech therapy or vocational therapy needs requiring ongoing inpatient level care from that time forwards. The patient was discharged from therapies one month ago without having made significant progress. There is no indication in the submitted records of any ongoing formal therapy needs for the next three to six months based on the patients documented status. Accordingly, the skilled nursing facility services at issue and the requested skilled nursing facility services were not, and are not, medically necessary for the patients medical condition. In addition, the requested physical therapy, cognitive therapy, vocational therapy, and speech therapy for three to six months are not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 62-year-old female who indicates she has a 10-year history of allergies and asthma. The patients allergist indicates the patient has persistent allergy mediated asthma. The submitted clinical records show an IGE level of 15.9IU/ML. There is no mention in the submitted records of the frequency of prednisone bursts. Pulmonary function studies have not been provided.  The patients allergist has recommended a 12-month trial of Xolair. The Health Plan has denied authorization for the requested medication on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The clinical information provided does not demonstrate the patient meets medical necessity criteria for authorization of Xolair. As noted above, the frequency of prednisone bursts is unknown and symptoms of steroid dependence are not documented. Nor is there documentation the patient required emergent treatment. Furthermore, there is no documentation of a spirometric study or a positive allergy skin test. Moreover, it does not appear consideration has been given to other diagnoses, which may be contributing to the patients asthmatic symptoms (e.g., reflux). Based upon the information provided, it has not been demonstrated that use of Xolair is medically warranted. Accordingly, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.