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

The patient is a 50-year-old female who had an onset of tinnitus in 2004 with increased symptoms in December 2004 and January 2005. The tinnitus disturbs her sleep. Tinnitus matching was performed and matching occurred at 6000 hertz. The patients providers have recommended a GHI Tranquil RR sound generator for treatment of the patients tinnitus. The Health Plan has denied this request. Tinnitus retraining therapy is a new form of treatment for tinnitus involving sound generators. Although it is showing some promise in the treatment of tinnitus, there is still insufficient evidence demonstrating its long-term effectiveness. Because of this lack of evidence the Health Plan is correct that the medical necessity of sound generators in the treatment of tinnitus has not been demonstrated. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Care Assist Bed System with a P500 air mattress. for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewer found that a review of the literature and Care Assist Bed System with a P500 air mattress reveals that this bed and mattress has features which do not primarily serve a medical need, rather convenience items. The documentation indicates that the patient is at risk for pressure ulcers but does not reveal physical examination findings of the patient with current evidence of pressure ulcers or skin breakdown. The records do not document failure of current conservative repositioning and skin care/wound prevention routine. Durable medical equipment (DME) is primarily used to serve a medical purpose and the requested equipment exceeds the patients needs based on the available documentation. There is no evidence that the patients current needs cannot be met with a standard hospital bed and air loss mattress. Thus, the requested Care Assist Bed System with a P500 air mattress is not medically necessary.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

A 49-year-old female enrollee has requested participation in a Phase III stem cell transplantation trial at the University of Arkansas for treatment of multiple myeloma.  Findings:  The physician reviewer found that Autologous peripheral stem cell transplant is considered a standard treatment approach to myeloma that has progressed after induction therapy. This approach is endorsed by NCCN guidelines. There is no other therapy available in this setting that is likely to be superior to the proposed clinical trial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Sovaldi and Daklinza for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested for Celebrex 200mg for treatment of her degenerative arthritis of both knees. Findings:  The physician reviewer found that the patient has had a trial of two NSAIDs without improvement in her pain. In addition, she has chronic gastric carditis, and has experienced significant gastrointestinal upset with Mobic, ibuprofen and Naproxen. The COX-2 inhibitor Celebrex is medically indicated since the patient has failed a trial of Mobic, ibuprofen and Naproxen.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Skyrizi. The 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis (PsA) recommended treatment of PsA with tumor necrosis factor inhibitors (TNF1) over an interleukin-12/23 (IL-12/23) biologic. A study noted that an IL-12/23 may be considered if the patient has severe psoriasis, prefers less frequent drug administration, or has contraindications to TNF1 biologics. While the study noted some data supporting the use of selective inhibition of IL-23 to treat PsA, its use is fairly new. In this case, the patient has plaque psoriasis, and the provider noted that he has arthritis. Skyrizi is not the recommended therapeutic for a patient with psoriatic arthritis. In this patients case, the records do not support the use of Skyrizi. Therefore, Skyrizi is not medically necessary 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested has requested authorization and coverage for total hip arthroplasty for treatment of his hip pain. Findings: The physician reviewer has found in this patients case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Specific guideline criteria include exercise therapy (supervised physical therapy and/or home rehabilitation exercises) and medications (unless contraindicated, non-steroidal anti-inflammatory drugs or steroid injection). Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include patients 50 years and older with a body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations include exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. This patient presents with severe and worsening left hip pain. There is imaging evidence of bone-on-bone osteoarthritis, which would warrant an exception to peer reviewed guideline/literature recommendations relative to age. His calculated body mass index is less than 30. He has significant functional difficulty in weight bearing and activities of daily living. There is limited range of motion, and nighttime joint pain. There is imaging evidence of advanced osteoarthritic changes in the left hip, reported as bone-on-bone. He is status post right total hip arthroplasty with good results. Recent conservative treatment had included activity modification, over the counter medications, and home exercise program. Given the severity of the degenerative changes, additional conservative treatment would not typically be supported prior to surgery. Therefore, the request for total hip arthroplasty is 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 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 parent of a 17-year-old male enrollee has requested group, individual, and family therapies for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that given this patient's presentation, he was a candidate for outpatient services during the period under review. The clinically reasonable therapeutic services for this patients medical condition should have consisted of individual therapy, substance abuse group therapy, and family therapy. This conclusion is consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for oppositional defiant disorder and substance use disorders. As such, the medical necessity has been established for individual therapy sessions, substance abuse therapy sessions, and family therapy sessions provided during the period at issue.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 48-year-old female who has chronic fatigue syndrome. She is requesting authorization for Benicar to treat her condition. The Health Plan has denied the patients request indicating the requested medication is considered experimental for treatment of chronic fatigue syndrome. The Health Plans denial should be upheld. Benicar is an anti-hypertensive medication. There is no literature supporting its use in chronic fatigue syndrome. There is no evidence the patient will benefit from the requested medication. Therefore, I have determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 48-year-old female with chronic fatigue syndrome in a Marshall protocol and wants to use Benicar, an anti-hypertensive drug. Her blood pressure is 80/50/50-60. The Health Plan has denied authorization and coverage for Benicar on the basis the drugs efficacy has not been established for treatment of chronic fatigue syndrome.Benicar is an anti-hypertensive drug. The patient does not have hypertension. Off-label use in chronic fatigue syndrome is experimental and is not likely to be effective. There are other appropriate therapies available for treatment of the patients condition. Therefore, I have determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 48-year-old woman who has chronic fatigue syndrome. Her physician notes the patient has researched chronic fatigue syndrome and believes Benicar is an appropriate treatment for her condition. Current symptoms are not described. No laboratory data is presented. The Health Plan has denied authorization and coverage for Benicar on the basis it is considered experimental for the patients diagnosis.No data has been submitted that meets relevant criteria showing the patient actually has chronic fatigue syndrome or that chronic fatigue syndrome is responsive to Benicar.  Review of the relevant medical literature revealed no data on Benicar for treatment of chronic fatigue syndrome.  Furthermore, there is no data regarding use of Benicar in Th1 inflammatory disease. The only relevant article involves ACE enzyme as a marker for chronic fatigue immune dysfunction syndrome and comparison to ACE in sacoidosis. However, there was no information in that study to support treatment with one ACE/ARB over another. Based upon the information set forth above, I have determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the evaluation of her medical condition. Findings:  Three physician reviewers found that the ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed. While the lack of interval change when compared to prior mammograms is reassuring, tomosynthesis does offer the ability, in dense breasts, to better detect early recurrence. Given the above, breast tomosynthesis was 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 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 reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested posterior tibial nerve stimulation (PTNS) for evaluation of the enrollees urinary urgency, frequency and nocturia.  Two physician reviewers found that the medical literature supports the use of PTNS as a third-line therapy for the treatment of urinary frequency, urgency and incontinence in those who have failed medical management (first and second line therapies). In this case, the use of PTNS based upon the patients limited medication trials and signs of improvement with only initial pelvic floor training would fall outside the standard of care. In sum, there is a lack of evidence supporting that PTNS would be more therapeutic than other available second-line therapies for this patient. For the reasons provided, PTNS was not and is not likely to be more beneficial than standard medical therapy in this clinical setting.  Final Result: Two reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  All three reviewers are board certified in urology 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 a five-year-old male enrollee has requested general anesthesia to be administered during a dental procedure for treatment of the enrollees early childhood caries.  Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often used to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for extensive dental treatment makes general anesthesia an appropriate treatment modality for pediatric patients. Forsyth and colleagues reviewed and collected data from general anesthesia records for over 700 pediatric patients over a two-year period. The authors reported that general anesthesia allowed for comprehensive and high quality dental care especially in young patients who required extensive dental treatment. Bader and colleagues noted that the most common indication for general anesthesia was the childs inability to cooperate and undergo dental treatment. According to this patients provider, the severity and extent of dental caries, possibility of dental abscess, and inability to cooperate, support the medical necessity of the requested general anesthesia services for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing rehabilitation services. Functional impairments due to acquired brain insults such as stroke can be profound. Some recovery is expected with time, and many of these impairments are addressable by compensatory measures and directed rehabilitation efforts. The current standard of care for this condition includes rehabilitation services. Initial treatment may be in the inpatient setting, followed by rehabilitation in the community setting if indicated. The determination for level of care focuses on a patients impairments and the potential for achieving practical, functional goals. Most of the significant neurological and functional recovery following a stroke, notably, occurs in the early stages after stroke and gains are slower to come in the subsequent year. Rehabilitation efforts are appropriate at the lowest level of intensity commensurate with deficits. This patient sustained a stroke resulting in right upper greater than lower hemiparesis. She had grossly functional range of motion in the limbs and was at the contact-guard assistance level for her household mobility. She continued to require some assistance for self-care. The patient was stable enough for further rehabilitation in the community setting with custodial level assistance for safety outside of therapy sessions. There are no documented indications that the patient has ongoing functional goals, medical needs, or nursing issues requiring further skilled nursing rehabilitation services. Therefore, the skilled nursing rehabilitation services were not and are not medically necessary for treatment of this patient. 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 reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Daklinza and sofosbuvir for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi (sofosbuvir) and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population. The information provided is sufficient to meet the recommendations in the guidelines. Furthermore, delay in treatment may result in decreased survival. For these reasons, hepatitis C treatment is needed, and sofosbuvir with Daklinza for 12 weeks is s medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 52-year-old female enrollee has requested Botox injections for treatment of her medical condition.  Findings:  Two physician reviewers found that the requested Botox injections are not likely to provide significant benefit over other standard treatment.  There is a lack of support for the requested services in this patients case.  Scientific data suggests that Botox injections may reduce the frequency and severity of migraine headaches.  However, the clinical documentation submitted for review does not support Botox injections in this setting.  Specifically, the clinical documentation did not clearly identify a reduction in the number of headaches per month, nor did the documentation provide evidence that the previous Botox injection reduced the severity of the migraine headaches.  Thus, Botox injections are not likely to be more efficacious than other treatment alternatives.