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

The patient is a 53-year-old female who is requesting Provigil for the treatment of her fatigue related to multiple sclerosis. Based on a review of the records, the diagnosis does not appear to be in dispute. The patient remains gainfully employed despite significant fatigue. The patient was provided with samples of Provigil in January 2006 and the medication was effective in the treatment of her fatigue. The patient has requested authorization for continued treatment with Provigil.  The Health Plan denied her request based on a determination that the medication is not medically necessary for treatment of her MS-related fatigue.There is no dispute of the patients diagnosis, nor the condition necessitating the treatment, fatigue related to multiple sclerosis. The efficacy of the medication in the treatment of the patients symptoms has been established. The Health Plan denied the treatment as an off-label application citing a peer-reviewed article that concluded Provigil was no better than placebo in alleviating fatigue.  There are other studies, as cited above, that have reached the opposite conclusion. The data from the study published in JAMA suggests that 200mg per day of Provigil significantly improves fatigue and is well tolerated in patients with MS.Fatigue is similar to pain in that it is a perception and should be treated based on the patients subjective symptoms. As MS is a disabling and chronically progressive disease, if in the patients perception her fatigue is sufficiently improved to allow her to continue working, the decision to prescribe Provigil is medically appropriate.  The study cited by the Health Plan is not persuasive in light of the patients response, and has been challenged by other studies that indicated fatigue might be alleviated by Provigil.  Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery. Findings:  The physician reviewer found that evidence based medical guidelines recommend lumbar decompression surgery for patients with spinal stenosis secondary to degenerative processes exhibiting ligamentous hypertrophy, facet hypertrophy, and disc protrusion. Surgical indications include symptoms or findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Guideline criteria include evidence of nerve root compression, imaging findings of nerve root compression, lateral disc rupture, or lateral recess stenosis, and completion of comprehensive conservative treatment. A study reported that their systematic review of the recent literature demonstrates that decompressive surgery is more effective than land based exercise in the management of lumbar spinal stenosis. However, given the slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land based exercise be considered prior to consideration of surgical intervention. A study concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment when the latter had failed for three to six months. This patient presents with chronic low back pain radiating into the bilateral lower extremities, with numbness into the anterior lateral thighs to the feet. Signs and symptoms have been consistent with neurogenic claudication. Clinical examination findings have not demonstrated a focal neurologic deficit correlated with imaging evidence of nerve root compression. There is imaging evidence of mild to moderate bilateral neuroforaminal narrowing at L5-S1 due to facet hypertrophy. Evidence of long-term conservative treatment has been reported without sustained improvement. He has improved with multiple epidural steroid injections at the L5-S1 level. He has been diagnosed with bilateral meralgia paresthetica. There are no electrodiagnostic studies documented in the submitted medical records. Further, there is no documentation of a surgical consultation prior to consideration of surgery. Given these findings, the requested services are not medically necessary. 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 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for parent child interactive therapy (PCIT) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that typically, parent-child relational problem involves impairment of functioning in behavioral, cognitive, or affective domains, and there is little evidence demonstrating the patient has functional impairment in any of these domains. The records do not show arguments that escalate to threats of physical violence, there is no evidence of avoidance without resolution of problems, hostility or scapegoating, or unwarranted feelings of estrangement. In this clinical setting, standard therapies such as family and group therapies are medically reasonable for this patients issues. Final Result: The reviewer determined that the services at issue were not and are 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 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: Overturned

The patient is a 34-year-old woman with a BMI of 40 without significant comorbid conditions. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates the patient does not meet Health Plan criteria for authorization of gastric bypass surgery.With a BMI of 40 the patient meets nationally accepted criteria for consideration of weight loss surgery. Further, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure 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: The patient has requested authorization and coverage for Euflexxa injections. The records provided for review document that this patient presents with a history of osteoarthritis of the left knee. The patient has reportedly benefitted from a series of Euflexxa injections every six months for the last three years. The patient most recently underwent a series of injections. Physical examination at that time revealed restricted painful range of motion of the left knee with patellar grind, medial and lateral joint line tenderness, and normal range of motion of the right knee. The provider has documented the need for continued viscosupplementation with Euflexxa injections. 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, there is a history of lasting benefit from viscosupplementation using Euflexxa injections every six months for three years. Furthermore, the alternative is a total knee arthroplasty. For these reasons, the requested Euflexxa 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: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for Euflexxa injections to her right knee for treatment of her medical condition. Findings:  The physician reviewer found that Euflexxa (or visco-supplementation) injections are used in patients who have degenerative arthritic changes and have failed conservative care with activity modification, home exercise, anti-inflammatory medication, and a possible cortisone injection.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested acute inpatient treatment for treatment of her behavioral health issues.  Findings:  The physician reviewer found that the patients medical records do not clearly and adequately support the primary and secondary diagnoses. The providers first deny the existence of an eating disorder, and then describe the patients history of an eating disorder that had persisted for about three years. In addition, she was switched from the mood disorders program to the eating disorders program ostensibly because of age of the patient population and not due to her primary disorder. She had an EEG performed with positive findings, which were not apparently further investigated. Despite this disparity, the patient was prescribed at least one medication that could enhance seizures. Applying the criteria set forth by the American Psychiatric Association (APA), this patients records do not substantiate the clinical necessity for the intensive, 24-hour monitoring and supervision provided during the period at issue. The patients history and symptoms suggest that she could have been safely and adequately treated in a less restrictive level of care such as intensive outpatient program (IOP) or outpatient care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for hyaluronan/derivative Euflexxa IA injection per dose for treatment of the enrollees hip pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Piccirilli and colleagues performed a systematic review and meta-analysis regarding hyaluronic acid (HA) injections in hip disorders. The authors concluded that there is a lack of standardization of HA injections for hip conditions. Their results suggested that this is the best conservative therapy before surgery and it can act on pain relief and function. However, the authors noted there is no evidence to prove its ability to modify the morphological structure of the pathological hip and the natural history of the disease. There are few data about the use of HA in other hip disorders rather than osteoarthritis. Leite and colleagues did not recommend viscosupplementation for hip osteoarthritis. This patient presents with chronic left hip pain with functional limitations in work and activities of daily living noted. She has been diagnosed with left hip arthralgia, adductor muscle strain, degenerative acetabular labral tear, and femoroacetabular impingement. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is no radiographic evidence documented of osteoarthritis of the left hip. There is limited support in current evidence-based literature for viscosupplementation (hyaluronic acid injections) as an option for patients with severe hip osteoarthritis to delay total hip replacement. There is a lack of evidence to support the use of viscosupplementation in other hip disorders. Therefore, hyaluronan/derivative Euflexxa IA injection per dose are not medically necessary for the treatment of this patient.  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 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 reimbursement for the tumor necrosis factor (TNF) antagonist blood test for evaluation of the enrollees Crohns disease.  Findings: Three physician reviewers found that TNF antagonist blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab (IFX) or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation 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 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 Botox injections for the treatment of migraine headaches.  Findings:  Two physician reviewers found that although Botox is not FDA approved for the treatment of migraine headaches, it is often used for the prevention of medication resistant headaches. However, a patient should have adequate trials of three or more prophylactic medications before treatment with Botox is indicated. These medications should be from several different classes, such as anti-depressants, anticonvulsants, beta blockers and calcium channel blockers.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prostate cancer screening. Findings:  Three physician reviewers free PSA can be used to assess an added probability of finding cancer in a group of patients with this PSA, but the presence or absence of cancer in one patient can be confirmed by biopsy or on follow-up. The overall benefit from testing can help patients and providers choose their next steps with added confidence, but this testing has not been demonstrated to be more reliable than biopsy in this clinical setting. Thus, the prostate cancer screening was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the prostate cancer screening was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for liposuction and an abdominoplasty.Findings:  The physician reviewer found that World Professional Association for Transgender Health (WPATH) standard of care lists as treatments for gender dysphoria for transgender men: Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures. Additionally, WPATH states, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. In this case, the patient has been diagnosed with gender dysphoria. Records indicate that the patients abdominal contour contributes to his gender dysphoria. Thus, liposuction and an abdominoplasty are medically necessary for treatment of the 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 psychiatry with expertise in transgender 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 50-year-old male who has a long-standing history of cocaine addiction and bipolar disorder. The patient was admitted to a residential treatment program on 3/10/04. A request has been made for reimbursement for patients stay in the residential treatment program. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients behavioral health problems. Review of the submitted documentation indicates the patient could have been managed in an intensive outpatient setting. The emergency room initial conduct assessment form states the patient was experiencing auditory and visual hallucinations though the content of hallucination was not described. The patient has denied suicidal ideation. It appears the hallucinations were related to intravenous use of cocaine and were self-limited. A medical/chemical dependency consultation performed on 3/11/04 does not reference hallucinations. At that time it was noted the patient was angry and disturbed, but showed only a slight behavior change. It was further noted that no active therapy was needed at that time. A rehabilitation program on either an inpatient or outpatient basis was recommended. The submitted treatment notes indicate the patient demonstrated clear insight into his dependency issues, though he maintained ambivalence. It appears the patient also has had the support of his wife. As such, according to the American Society of Addiction Medicine Criteria Dimensions the patient was an appropriate candidate for intensive outpatient treatment. Thus, treatment at the residential level of care was not medically warranted.Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for the prescription medication Lyrica for treatment of her fibromyalgia. Findings:  The physician reviewer found that the adverse effects reported for both Neurontin and Lyrica are essentially the same. Actually, there are more adverse effects in the greater than 10% category associated with Lyrica than with Neurontin. Arthralgia, lethargy, fatigue, muscle spasm, myalgias, vomiting, confusion, weight gain and flu-like syndromes are among the adverse effects noted in clinical trials of Lyrica. Arnold and others found Neurontin to be helpful for the pain of fibromyalgia and generally well tolerated. A trial of Neurontin before taking Lyrica is clinically reasonable and consistent with the community standard of care. However, should Neurontin prove to be ineffective or not well tolerated, authorization of Lyrica should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavior analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: Two reviewers found that ABA is effective in helping with maladaptive behaviors in school age children with autism. In addition, Hassiotis and colleagues concluded that ABA significantly increased community participation and decreased carer burden for children with autism and challenging behaviors. An abrupt discontinuation of ABA services is not indicated because it often causes regression. Thus, the continuation of ABA services are medically necessary. However, the requested frequency of ABA services are not indicated for this patient. In this case, a portion of the requested hours per month of ABA therapy, the requested hours per month of supervision and the requested hours per month of parent training provided forward was and is medically necessary for treatment of the patients autism.Final Result: Two reviewers determined that the portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in pediatrics and child 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.