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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 1b.  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response, which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Accordingly, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  Final Result:  Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male has requested  speech therapy services for treatment of his autism. Findings:  The physician reviewer found that the medical literature indicates that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism spectrum disorders. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old man who was diagnosed with HIV in 1995. The patient has been diagnosed with facial collapse grade IV lipodystrophy. He has requested subcutaneous facial augmentation to reconstruct the contours of his face. The Health Plan has denied the request indicating that the requested procedure is cosmetic in nature and is not medically necessary.Upon review of the submitted documentation, including photographs of the patient, there is no evidence of intertrigo, rashes, erythema or lacerations. Furthermore, the cheek is not a functioning unit and there is no evidence of a structural abnormality. Thus, the requested procedure is not reconstructive in nature and therefore, is not medically indicated. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services assists providers in determining the appropriate level of care. With regards to risk of harm, the records support a score. During the dates in question, the patient had passive suicidal ideation with no intent or plan. In terms of functional status, the records support a score. The patient had ongoing severe deficits in her interpersonal relationships. With regards to medical/addictive/psychiatric comorbidity, the records support a score. The patient had diagnoses of bulimia nervosa, moderate, major depressive disorder, and posttraumatic stress disorder. In terms of recovery environment, the records support a score. The patient had discord with her family. With regards to level of support, the records support a score. The patient reported a history of abuse. However, the patients boyfriend offered support. In terms of treatment history, the records support a score. The patient was cooperative with treatment. She continued to struggle with chronic depression and body image problems. With regards to engagement and recovery status, the records support a score. The patient was engaged with treatment. She was able to form a positive relationship with staff and clinicians. Thus, the records support a composite score. Based on these criteria, the patient met criteria for intensive outpatient program level of care. Thus, the patient could have been treated in a less restrictive environment. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer 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.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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old male with an apparent history of attention deficit hyperactivity disorder (ADHD) and associated symptoms for many years. The patients past treatment has including Strattera, Lexapro, Effexor, and stimulants without apparent benefit. No other medications or treatment is mentioned. According to the patient, Provigil helps decrease his ADHD symptoms. A request has been made for authorization and coverage for Provigil. The Health Plan has denied the request on the basis that Provigil is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Though Provigil has been used for multiple off-label illnesses and indications, reports of the efficacy of Provigil for treatment of adult ADHD are anecdotal. In addition, the records submitted do not provide evidence of any formal evaluation of the patient for ADHD (e.g., psychiatric testing, TOVA screening, etc.). Furthermore, there is no indication that the patient has undergone a trial of combinations of stimulants and selective serotonin reuptake inhibiting drugs and/or tricyclic antidepressants. Nor do the submitted records indicate that all stimulants have been prescribed without success. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested a continuous glucose monitoring system for the treatment of the enrollees type I diabetes mellitus. Findings:  Three physician reviewers found that the proposed continuous glucose monitoring system is a medically appropriate adjunct to the patients diabetic control. The alarm system will permit her to have lower blood glucose excursions during the night, while the detailed glucose measurements provided by the device will allow for better incremental insulin interventions throughout the day. The use of the requested device is medically reasonable in this setting and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her behavioral health issues.  Findings:  The physician reviewer found that there are several factors in this case that deserve attention and make transcranial magnetic stimulation (TMS) inappropriate for this patient. The first issue is that she suffers from severe flashbacks and much of her symptomatology is related to her PTSD. In addition, she has a history of eating disorder symptoms that have included binging and purging. Further, her diagnoses of PTSD, GAD and insomnia do not appear to have changed in several years and none are currently recognized diagnoses that are being treated by TMS. The medical literature suggests that the FDA indication for TMS is for depression. In addition, an overwhelming majority of the literature in support of TMS has been published on its use in patients with depression and not anxiety, possible eating disorder, or trauma-based diagnoses. In summary the medical necessity of the requested TMS therapy has not been demonstrated in the instant case. While there is data to support the use of TMS for depression, the above-discussed reasons do not support the use of TMS in this patient over conventional treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. The records provided for review document that this patient has experienced symptoms consistent with psoriasis for about nine years. In 2016, he reportedly had psoriasis with involvement of about 5% of his BSA. By July 2020, the patient had greater than 70% of his BSA covered with psoriasis. According to the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) joint guidelines, psoriasis is categorized as mild, moderate, and severe. Per these guidelines, severe psoriasis is characterized by involvement of more than 10% of a patients BSA. Based on this patients physical examination, this patient has evidence of severe disease. Researchers noted that although mild psoriasis is generally treated with topical therapies, severe disease supports treatment with biologic agents. This patients provider has recommended treatment with Otezla. However, the records do not document any contraindications to standard of care biologic agents. Given the AAD and NPF guideline recommendations, this patient is a candidate for treatment with an injectable biologic prior to treatment with Otezla. Biologics have been shown to be effective in treating psoriasis with reasonable safety profiles. Otezla does not fall into the biologic category. For these reasons, the requested Otezla 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 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: Overturned

A 55-year-old male has requested brand name Glucophage for treatment of his type II diabetes.   Findings:  The physician reviewer found that based on review of the available records, this patient was treated with generic metformin extended release (XR) or slow release metformin as well as brand name Glucophage. It is well known in clinical diabetology that the XR form of metformin is tolerated by a significant number of patients who could not tolerate regular metformin or Glucophage. This patient was given the generic, which is generally a better tolerated form of metformin, yet he experienced GI side effects. In addition, the records indicate the patient did not have GI side effects with Glucophage. Therefore, it is reasonable to give the patient the form of the metformin that he was able to tolerate. As such, the requested brand name Glucophage is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested for homeopathic treatment for treatment of his skin condition.  Findings:  The physician reviewer found that the peer-reviewed journals do not include any studies that would validate this form of therapy, only some personal testimonials. The homeopath the patient wishes to see is not licensed to practice medicine according to published literature. Furthermore, a multidisciplinary approach is more likely to uncover factors contributing to the patients ongoing dysesthesias, which may include alcohol dependence, an underlying affective disorder and persistent disability thinking.
Appeal type: Medical Necessity
Decision: Overturned

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

A 43-year-old female enrollee requested wireless capsule endoscopy for medical evaluation of her medical condition.Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more efficacious than other methods of evaluation.  This patient presented with dysphagia and gastroesophageal reflux disease symptoms.  Wireless capsule endoscopy does not have a role in this clinical settingThis patient already had esophageal manometry, which is the gold standard esophageal motility study.  Therefore, wireless capsule endoscopy was not likely to have been of greater benefit than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lazanda (fentanyl) nasal spray for treatment of her breakthrough pain. The physician reviewer found that Lazanda (fentanyl) nasal spray is not medically necessary for treatment of this patients chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsant medications and anti-depressants considered adjunctive to this therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Baron and McDonald reported that 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 Mao 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. It is thus in this patients best interest to wean off opioids and continue in a multidisciplinary program. Consistent with these findings, the requested Lazanda (fentanyl) nasal spray is not medically necessary.  Final Result: The reviewer determined that the requested medication is 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested oxycodone for treatment of his medical condition. Findings: The reviewer found that there is a lack of support for the requested medication in this patients case.  Per the records, behavior therapy has been started but has not been completed despite research to support its use.  Additionally, there is a lack of documentation of optimization of other evidence-based, non-opioid medications for pain.  Rather, large doses of opioids are being used, without a clear rationale for such a high dose despite research to show the dangers of a high dose and it lacking efficacy for quality of life.  The records indicate that tolerance has taken place since the start of the narcotics.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. Moreover, the records do not discuss other standard lower extremity neuropathic pain treatments.  All told, the requested oxycodone 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

The patient is a 36-year-old female with constipation predominant irritable bowel syndrome (IBS). Although the patient has responded to therapy with Zelnorm, she quickly relapses once therapy is discontinued. Relapse of her IBS has resulted in painful perianal disease that has required surgery in the past. The Health Plan has denied authorization for Zelnorm therapy on the basis that it is not medically necessary for treatment of the patients IBS.Though it has been suggested that the Food and Drug Administration (FDA) has approved the use of Zelnorm for 4-6 weeks with one repeat, the FDA actually suggests that therapy for 12 weeks should be considered in those patients who respond by 4-6 weeks. The FDA approval never discusses repeat dosing. Furthermore, labeled indications for any drug do not necessarily reflect standard of care or prudent use. Moreover, the Health Plans suggestion of safety issues similar to those of alosetron are unwarranted as no patient of the 11,000 in the Zelnorm clinical studies has developed ischemic colitis, and the rate of ischemic colitis seen post-marketing with this component is no greater than population estimates of IBS patients suggest they should be. The Zelnorm results are very different from the alosetron data. Alosetron is a very different compound with a different mechanism of action; more importantly, alosetron is used in a different population of patients with a different disease. While Zelnorms current label dose is 6mg twice daily for up to 12 weeks and no published studies exist beyond 12 weeks, it is clear that no one dose and duration of this drug (or any drug) is the most effective dose for all patients with this disease (or any disease). As IBS is a chronic disease, it is well recognized that many patients will either relapse following cessation of therapy and therefore, require re-treatment or require maintenance in order to control their symptoms. Clinical experience with this compound in many millions of patients over the last two years is more than adequate evidence to support this pattern of use.In light of the information set forth above and given the patients good clinical experience with Zelnorm with no evidence of toxicity or side effects, continued use of Zelnorm is medically appropriate and indicated. Therefore, I have determined that 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

A 38-year-old male enrollee has requested bariatric surgery for treatment of his obesity.  Findings:  The physician reviewer found that based on review of the available records, although this patients records support a diagnosis of clinically severe obesity with a BMI of at least 35 with history of sleep apnea, the medical necessity for bariatric surgery is not supported at this time. The patients records do not include documentation of previous dietary efforts. In addition, there is no documentation of any multidisciplinary evaluation that would include medical clearance, dietary evaluation and behavioral evaluation as part of standard nationally accepted criteria such as the National Institutes of Health (NIH) consensus guidelines. Therefore, the requested surgery is not medically necessary for treatment of this patients medical condition at this time.