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 Norco 10/325 mg two tablets daily for treatment of the enrollees back, neck, abdomen, and shoulder pain.  Findings:  The physician reviewer found that Guidelines offer specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose should be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. In addition, providers of opiate medication should provide documentation of the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. This patients records do not include documentation that the use of the prescribed opioid medication did or will decrease the level of pain reported from one visit to the next. In addition, there is no noted functional improvement or improved pain noted during the duration of the prescription for Norco. Moreover, there is no indication that first-line agents such as non-steroidal anti-inflammatory drugs (NSAIDs) have been trialed and failed to provide adequate pain relief. Final Result: The reviewer determined that the requested medication quantity 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 neurology 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 seven-year-old male with a diagnosis of high-functioning autism with documented severe language delays as shown on the clinical evaluation of language fundamentals revised (CELF-R). He also has mild oral-motor impairment, severe receptive language and expressive language skills. The patient is in a special day class at school and receives speech therapy twice per week. The evaluating therapist has recommended additional speech therapy two times per week. The Health Plan has denied authorization and coverage for the requested therapy on the basis that it is not medically necessary for treatment of the patients condition.Review of current medical literature reveals no evidence that intensive speech therapy at four times per week is superior to the amount of therapy the patient is already receiving. Additionally, the speech therapist who recommended more intensive therapy did not identify specific goals establishing the need for the additional therapy. The submitted evaluations do not delineate between the goals of therapy performed by the school and the goals established through additional therapy. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested partial hospitalization eating disorder program services for treatment of her eating disorder. Findings:  The physician reviewer found that the patient did not respond to intensive outpatient treatment and was admitted to the partial hospitalization program for this reason. She was experiencing relatively serious medical complications and required emergency treatment for significant bradycardia. Although she was not overtly suicidal, homicidal, aggressive or psychotic, it would not have been appropriate for her to return to an outpatient program since she had previously failed to respond to such a program. The patient did require treatment in a partial hospitalization eating disorder program. She was not progressing satisfactorily during the relatively short time she was in this program. It would be unsafe and not prudent to recommend a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation.American Society of Interventional Pain Physicians evidence-based guidelines for interventional techniques state that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. A systemic review by Manchikanti and colleagues found that in the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy. Researchers found that there was a reduction in pain 12 months post-procedure for patients with facet joint disease of the lumbar spine. Researchers found that radiofrequency ablation of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to 2 years. This study investigated function, pain, and medication use outcomes of radiofrequency ablation for lumbar facet syndrome in a cohort with long-term follow-up.In this case, the patient has a diagnosis of lumbar facet arthropathy with a presentation of chronic low back pain. The patient underwent a previous lumbar radiofrequency ablation procedure of the L3 through S1 medial branches, and notes from a follow-up visit confirm that the patient received significant pain relief which lasted approximately 6 to 8 months before the pain gradually returned. The patient has therefore had a previous positive response to the radiofrequency ablation procedure that is now requested. The requested radiofrequency ablation is also consistent with current standards of care as well as recommendations from current pain management guidelines and evidence based literature. Accordingly, the requested radiofrequency ablation is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominal and leg ultrasounds.  The Health Plan denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees chronic abdominal pain, right knee joint pain and right knee arthritis. Regarding the request for an abdominal ultrasound, researchers compared the accuracy of CT scans versus ultrasound in patients with abdominal pain. They found that CT scans were more accurate and able to detect both soft tissue, viscus and bone abnormalities more accurately than ultrasound. Since the patient has already had two normal CT scans recently, ultrasound would be expected to add little additional information for pain management, and is therefore not medically necessary. With respect to the request for leg ultrasounds, the American College of Radiology does not recommend ultrasound for evaluation of patients with chronic knee pain.  Magnetic resonance imaging (MRI) of the knee taken previously confirmed the osteoarthritis in the right knee. Although the patient has a distant history of pulmonary embolism, an ultrasound previously showed only mild greater saphenouos vein reflux. A physician exam previously did not show low leg edema or calf tenderness. In the absence of demonstrable warning signs (edema, calf tenderness), a repeat ultrasound is unlikely to add any additional management information beyond the already performed MRI and ultrasound. Therefore, ultrasounds of the legs are not medically necessary.Final Result: The reviewer determined that the services at issue are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology 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 is a 34-year-old male who sustained an anterior cruciate ligament (ACL) tear and underwent ACL reconstruction. An electronic controlled thermal therapy unit (cold therapy unit) was utilized postoperatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, he experienced better pain relief and less swelling than would have been expected with ice packs alone. Therefore, I have determined the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla 30 mg tablets. Based on the guidelines from the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF), patients who have 3-10% BSA involvement have moderate disease, while patients with 10% or more BSA involvement have severe psoriasis. Patients with severe psoriasis are candidates for phototherapy and systemic medical therapy. However, there are no step therapy guidelines, and the choice of therapy should be made at the discretion of the treating provider with attention paid to the patients comorbidities. Otezla is U.S. Food and Administration (FDA) approved for the treatment of moderate to severe psoriasis and has Level A evidence to support its efficacy. Given that this patient has documented evidence of severe disease with a BSA of 15%, the requested medication is consistent with the AAD and NPF guidelines. Given this support, the requested Otezla 30 mg tablets are medically necessary for 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 dermatology with subspecialty certification in dermatopathology 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 Norco for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is a lack of support for chronic use of short duration opiates for osteoarthritis.  The use of chronic opiates requires a separate assessment of risk, urine toxicology screening, the formulation of a plan to assess progress and the execution of an opiate maintenance agreement.  The records do not document these requirements in this patients case.  The current medical evidence does not support Norco in this clinical setting.  The use of Norco for over 16 weeks has not been intensively studied for safety and ongoing efficacy.  Therefore, the requested Norco is not medically indicated 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old male enrollee has requested authorization and coverage for one hour individual speech therapy sessions once per week. The requested one hour individual speech therapy sessions once per week is medically necessary for treatment of the patients medical condition. The records indicate that the patient has a duplication at chromosome 22q11.2, a condition well recognized as resulting in significant speech and language impairment. In addition to cognitive impairment in chromosome 22q11.2 duplication, studies noted that one of the prevalent and serious problems encountered by patients with the 22q11.2 deletion is difficulty with speech. This may be due to a number of factors such as adenoid hypoplasia, muscle hypotonia, platybasia, upper airway asymmetry, and neuroanatomical abnormalities. This patient has made significant progress in speech therapy, with improvement in his apraxia of speech. However, his speech is still only 75% intelligible, which will lead to difficulty in social interaction with his peers, and may contribute to behavioral and psychological disorders if untreated. Given these findings, the requested one hour individual speech therapy sessions once per week is supported as medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child neurology 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 enrollee has requested authorization and coverage of Harvoni 90-400 mg tablets. Findings:  The physician reviewer found that guidelines 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, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg tablets 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for vedolizumab (Entyvio) infusions in combination with subcutaneous ustekinumab (Stelara). Several studies have assessed the safety and efficacy of combination therapy Stelara with Entyvio in the treatment of patients with Crohns disease. Researchers concluded that, there was an increased risk of serious infection compared with biologic monotherapy. In addition, there are a lack of data demonstrating that combination therapy with Stelara and Entyvio is more effective than standalone therapies. Researchers concluded that, Further studies, as randomized control trials, to provide comparative efficacy and safety endpoints of combination therapies, and to clarify potential advantages of combined biological therapies, are needed. Overall, the use of Stelara with Entyvio is not supported by current guidelines or studies for use in lieu of conventional therapies. For this patient, the records document inadequate response to Stelara monotherapy. This patients records document a history of Crohns disease, but there is a lack of report that the patient has failed Entyvio monotherapy. All told, Entyvio infusions in combination with subcutaneous Stelara are not 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 Entyvio infusions in combination with subcutaneous Stelara are not 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 medication regimen is 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: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for CPT code 29891  arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia; CPT code 29892  arthroscopy aided repair of large osteochondritis dissecans lesion; and CPT code 28446  open osteochondral allograft, talus (includes obtaining graft(s)) for treatment of her right ankle pain. Findings:  The physician reviewer found that the records provided for review document that this patient has failed two previous arthroscopic procedures for her ankle cartilage injury. She is not a candidate for autograft transfer due to the lesion involving the medial shoulder of the talus. The time expected to fully heal from this procedure is approximately one year, and the patients schooling and activity level will be affected. Given the large lesion that has failed two previous surgeries, the medical literature supports the requested procedures for use in this clinical setting. 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one-on-one discrete trial training (applied behavioral analysis (ABA) services), 12 hours per week, and one-on-one monthly onsite supervision for parents 10 hours per month for treatment of the enrollees medical condition. Findings:  The physician reviewer found that based on the clinical documentation provided for review, the diagnosis of autism spectrum disorder has not been established. An in-Plan evaluation by a developmental pediatrician assessed the patient with expressive language delay. The patients out-of-Plan assessment noted a diagnosis of autism disorder based on DSM-4 criteria. An in-Plan evaluation was negative for autism. The patients parent report tantrum and non-compliance behaviors. However, these behaviors are not sufficient to support a diagnosis of autism. Given the lack of sufficient support demonstrating a diagnosis of autism spectrum disorder, the request for one-on-one discrete trial training ABA services, 12 hours per week, and one-on-one monthly onsite supervision for parents 10 hours per month are not medically necessary for treatment of 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 board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 has requested authorization and coverage for hydroxychloroquine 200 mg twice daily. The records provided for review document that this patients rheumatoid arthritis is stable with no current evidence of synovitis. Due to the potential side effects with long-term use such as retinopathy and peripheral neuropathy, it is reasonable to taper the patients hydroxychloroquine dose while her condition is stable. The records do not include documentation that the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD), which is required for all patients prior to receiving hydroxychloroquine. In patients with low G6PD levels, hydroxychloroquine has been associated with hemolysis. In addition, hydroxychloroquine is a long-acting agent and there is a low chance of a disease flare with a mild taper. The lower dose is safer over time, especially in this patient who is also taking Enbrel and methotrexate. Given these findings, the requested hydroxychloroquine 200 mg twice daily 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 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.