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

A 50-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of his hemorrhagic stroke.  Findings:  The physician reviewer found the records indicate that the patient sustained a severe stroke and that he is unable to participate in skilled therapy. His therapy consists primarily of passive range of motion, which does not require skilled nursing services. Continued daily skilled therapy is not indicated to improve or maintain his condition. He does not have daily skilled nursing needs as his condition is stable. All told, the SNF services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for plecanatide (Trulance) 3mg tablets. This 38-year-old patient had a history of chronic abdominal bloating and constipation. She had a gastrointestinal work-up, including colonoscopy. She was treated with Linzess, but continued to complain of constipation. Placenatide is approved by the Food and Drug Administration (FDA) for chronic idiopathic constipation. The FDA approval was based on studies showing that placanatide increased the number of bowel movements. The patient has evidence of chronic idiopathic constipation and the FDA has approved plecanatide for this usage. The patient has continued to have symptoms despite treatment with Linzess. The scientific literature has shown that there is a benefit to plecanatide. Based on the patients medical history, the current scientific literature, and the FDA listed indication, plecanatide is an indicated treatment for this patient.Final Result: The reviewer determined that the plecanatide (Trulance) 3mg tablets are medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing for prostate cancer. Findings:  Three physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed men with prostate cancer considering active surveillance as well as in previously treated men who are considering adjuvant therapy or treatment for recurrence.  Men with clinically localized disease may consider the use of tumor-based molecular assays.  Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups.  These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. This patient meets the National Comprehensive Cancer Network criteria for Oncotype DX testing.  In sum, Oncotype DX testing performed was likely to have been superior over other methods of evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 74-year-old male enrollee has requested continued skilled nursing services for treatment of his polio with leg weakness, abdominal aortic aneurysm, and congestive heart failure.  Findings:  The physician reviewer found that there is some low quality evidence of benefit of muscle strengthening interventions for improving strength and pain, but not necessarily function, in the setting of postpolio syndrome (Koopman, et al). Generally, inactivity and overuse of weak muscles should be avoided in the setting of postpolio syndrome, which may require physician and formal physical therapy supervision to educate and implement (Gonzalez, et al). The records provided for review document the patients conditions to include postpolio syndrome, metabolic encephalopathy, generalized deconditioning, and fatigue. He had undergone extensive inpatient rehabilitation. As of the date indicated and forward, his care has been custodial in nature and is not required at the skilled nursing facility level of care. The records do not support a reasonable likelihood of significant further functional gains with ongoing rehabilitative inpatient care. The records indicate that he has functionally plateaued at requiring significant assistance for his lower body ADLs and is only ambulating very short distances with assistance. In addition, there is no documentation of any active wound care, nursing or medical issues requiring ongoing inpatient care. Consistent with these findings, the skilled nursing services provided from the date indicated and forward were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent for treatment of the enrollee who has a history of coronary disease. Findings:  The physician reviewer found that The documentation provided supports the medical necessity for the requested medication in this clinical setting. Based on the records provided the patient has known coronary disease, elevated LDL cholesterol and documented inability to tolerate both statins and Zetia.  In this circumstance, a trial of a PCSK9 inhibitor is reasonable, appropriate and now considered standard accepted practice in the medical community.  PCSK9 inhibitors such as Praluent have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient meets the latter criteria since his LDL is elevated above goal and there is documented intolerance to both statins and Zetia which was used in an effort to lower LDL.  There is significant scientific literature that documents outcome benefits using PCSK9 inhibitors in this setting. For these reasons, Praluent is medically necessary for treatment of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the utilization of ABA therapy for the treatment of autistic adults, several medical studies demonstrate efficacy in relation to life skills, personal appearance, and toileting. According to the National Institute for Health and Care Excellence (NICE) guidelines for ASD in adults, ABA also plays an important role in the treatment of aggression and outburst behaviors in adults. In this case, the patient presents with frequent episodes of self-harm, along with occasional aggression toward others. These behaviors place the patient at an increased risk for injury. In addition, the Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. 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 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: Overturned

A 45-year-old female enrollee has requested for Ambien CR for treatment of her insomnia. Findings:  The physician reviewer found that Ambien CR is a controlled-release medication that can be more effective than Ambien or Ambien IR in a subset of patients due to its pharmacokinetic properties.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees mood disorder, impulse control, and polysubstance use. Findings:  The physician reviewer found that over the course of the PHP services during the specified time frame, the patient demonstrated improvement in terms of mood lability and impulsivity. She was actively participating in all spheres of her treatment. Her parents were noted to be supportive and attend family sessions. The patient did not demonstrate self injurious behavior, she was not aggressive towards others, and she denied suicidal ideation. She was compliant with her medication regimen. Given these findings, the American Psychiatric Association (APA) guidelines do not support the medical necessity of PHP services for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for laser therapy to treat hyperpigmentation. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patients hyperpigmentation does not constitute an abnormal structure of the body. It is a postoperative response of the patients skin following right upper eyelid ptosis repair and Vivaer intranasal remodeling. Therefore, the requested laser therapy to treat hyperpigmentation is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. The reviewer also determined that the patients hyperpigmentation did not constitute an abnormal structure of the body and that the requested services were thus not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for an open osteochondral allograft of the left knee. The enrollee suffered a knee injury while playing basketball. He was unable to ambulate. The enrollee underwent arthroscopic medial meniscus repair and partial lateral meniscectomy, and medial and lateral femoral condyle chondroplasty. A post-surgical re-evaluation reported the enrollee will need a second surgery to the medial femoral condyle and a chondral allograft. As noted by literature, osteochondral allograft transplantation to treat cartilaginous defects of the knee may be considered medically necessary when both the size of the cartilage defect is greater than or equal to 2 square centimeters in total area, as documented by magnetic resonance imaging or arthroscopy, and the condition involves a focal, full thickness, (grade III or IV) isolated defect of the weight-bearing surface of the medial or lateral femoral condyles or trochlear region. This enrollee has a reported cartilage lesion of 1 centimeter. The medical record documentation noted that the enrollee has full mobility with walking mobility. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and orthopedic sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an Orthovisc injection series in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of lasting benefit from Orthovisc injections. The records document pain relief and functional improvement of both knees from viscosupplementation. The medical evidence supports the requested services in this clinical setting. Therefore, an Orthovisc injection series in both knees is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for Emflaza. In a study of 196 boys with DMD aged five to fifteen, researchers concluded that, After twelve weeks of treatment, prednisone and both doses of deflazacort improved muscle strength compared with placebo. Deflazacort was associated with less weight gain than prednisone. Researchers also found lower functional decline with deflazacort compared with prednisone in the treatment of boys with DMD. Researchers studied the outcomes of long-term prednisone and deflazacort in patients with DMD and reported that, Deflazacort was also associated with a lower risk of scoliosis and better ambulatory function, greater percent lean body mass, shorter stature and lower weight, after adjusting for age and steroid duration. Medical literature noted the potential danger of changing between corticosteroid classes in DMD cardiomyopathy. In this case, the patient was switched to Emflaza due to weight gain and has been stable on Emflaza. The medical literature shows that deflazacort, as compared to prednisone, is more effective at slowing disease progression and is associated with a lower risk of scoliosis, greater percentage lean body mass, and less weight gain. Taking the patient off Emflaza in favor of prednisone would put the him at risk for the development of acute myocarditis. Therefore, Emflaza was and is medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her pain medication intolerance.  Three physician reviewers found that Cytochrome testing for opioid metabolism is not considered the standard of care to ascertain a patients intolerance to opioids. Moreover, the results of such testing will not assist in the ability to select the proper opioid to manage the side effects of nausea and vomiting. While genetic testing may help guide therapy in terms of codeine dosing parameters, routine pharmacogenetic testing based on common opioid related side effects of nausea and vomiting are not supported by the literature. Given these findings, gene testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld

A 70-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy with carboplatin 50mg for treatment of her ovarian cancer. Findings:  Three physician reviewers found that this patient has been diagnosed with stage IIIc ovarian cancer.  In this clinical setting, the standard of care is to offer optimal surgery followed by chemotherapy. There are clinical trials supporting first-line use of cisplatin in combination with paclitaxel.  The current medical literature has not established the superior efficacy of hyperthermic intraperitoneal chemotherapy in this patients case.  Thus, hyperthermic intraperitoneal chemotherapy with carboplatin 50mg is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an annual biopsy and gene marker testing for treatment of her right thyroid nodule.   The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for an annual biopsy and gene marker testing has not been established. Genetic testing is clinically indicated when the patient presents with atypical cells of underdetermined significance or follicular lesion of undetermined significance or follicular neoplasm. In this case, the nodule has been biopsied and aspirated and found to be benign. In addition, the request for an annual biopsy is not medically necessary. The patient should be evaluated clinically on an annual basis. If there is a change in size or local symptoms then a biopsy should be considered, if clinically indicated. For the reasons provided, an annual biopsy and gene marker testing is 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 endocrinology 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 59-year-old female enrollee has requested for residential treatment center for treatment of her alcohol dependence and major depressive disorder with psychotic features. Findings:  The physician reviewer found that utilizing the American Society of Addiction Medicine criteria for a Level III treatment facility, this patient meets criteria for residential treatment. She was a severe withdrawal risk which requires management in a Level III treatment facility. The American Psychiatric Association practice guideline for substance abuse/alcohol dependence states that patients should be treated in the environment that would be the most conducive for their treatment. Based on documentation, this patient should continue treatment at a residential level of care, as she was unable to maintain sobriety in an IOP program. All told, this patient has failed treatment attempts in a less restrictive setting and continues to have suicidal thoughts; therefore, residential treatment center services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested artificial disc replacement at L5-S1 using ProDisc II for the treatment of his back pain. Findings:  Three physician reviewers found that a study by Chou and colleagues indicates that, Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease, insufficient evidence exists to judge long-term benefits or harms. Although artificial disc replacement has been performed for many years as an alternative to lumbar fusion, mostly for degenerative disc disease causing chronic low back pain, the authors concluded that additional studies with greater follow-up are still needed to fully assess the outcomes of patients who undergo artificial disc replacement surgery. The conventional surgical treatment for recurrent disc herniation with radiculopathy is redo-discectomy. Since the medical literature fails to demonstrate the equivalence or superiority of artificial disc replacement, the requested surgery remains experimental. This patients problem is apparently his recurrent disc, which can be removed adequately with a re-operation discectomy and foraminotomy.