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

A 37-year-old female enrollee has requested Actiq 200mcg lozenges for the treatment of her Behcets syndrome. Findings:  The physician reviewer found that the patients diagnosis of Behcets syndrome is not at issue. She has had a complicated and difficult course with various problems related to her illness itself, as well as to medications used in treatment. The patient has pain of multiple sources, and has already received many different pain medications, including Duragesic patches. She now has pain related to bone infarcts and/or early osteonecrosis of her knees and hips. The knee and hip pain at issue can be expected to improve/resolve if due to bone infarction. The pain will otherwise likely worsen if due to true osteonecrosis, which would most likely lead to orthopedic intervention. Actiq is approved only for breakthrough cancer pain, and this patients presentation does not justify off-label use of this medication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to be treated with Harvoni, a Class I, Level A recommendation. These recommendations are based on multiple randomized clinical trials and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Lower sustained virologic response rate has been reported with Harvoni in patients with cirrhosis (Bourliere, et al).  Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary in this case.  Final Result: Two 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: One reviewer is board certified in certification in gastroenterology and is actively practicing.  Two 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: Upheld

A female enrollee requested use of a continuous passive motion (CPM) machine for medical treatment of her medical condition status post right hip arthroscopy.  Findings:  The physician reviewer found that based on the available documentation, the CPM device was not medically necessary during this patients recovery from a resection of a CAM lesion and labral repair at the right hip joint. The current data suggests that it is likely that gentle passive and active range of motion will accomplish the same benefits of rehabilitation during a patients recovery from the surgical procedure described. All told, the use of a CPM during this patients recovery status post right hip arthroscopy was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

This patient is an 18-year-old-male with a history of academic difficulty requiring an individualized education plan (IEP). He is currently in a non-public placement with a small class size. The patient has undergone significant educational and neuropsychological testing in the past.  The record indicates there is a possibility of a bipolar disorder and a history of depression was also noted. He has had several evaluations resulting in recommendations to the school district. Recently, he was evaluated by an audiologist for a central auditory processing disorder. The provider concluded the patient has a central auditory processing disorder which is affecting his academics and verbal IQ. She recommended AIT therapy or EASe Disc to improve auditory processing speed and to train for noise suppression; Fast ForWord to assist with processing speed; interactive metronome training to improve integrative function; individual work with an educational therapist on cognitive memory strategies; Making Math Real to improve math skills; and work with an educational or language specialist on Lindamood-Bell Visualizing and Verbalizing to improve verbal understanding and expression. The patients parent has requested reimbursement for the cost of the central auditory processing consultation and evaluation. The Health Plan denied the request based upon a determination that the services were not medically necessary.The case review included the patients central auditory processing evaluation as well as the IEPs provided. The record does not include a documented history of trauma, hearing loss or other disease or illness that can be associated with the symptoms attributed to the patient.  I also reviewed the scientific literature cited by the Health Plan and conducted an independent literature search of central auditory processing disorders. No additional literature on the topic was identified; there were no literature citations from the provider. I found no evidence to support the theory that a central auditory processing disorder is an illness, a disease process, or the result of trauma. In my experience, the symptoms described are generally associated with other learning disorders. Additionally, I found no data supporting the efficacy of the recommended therapies. As such, I cannot conclude there is a medical basis for the central auditory processing consultation and evaluation.  Based upon the information set forth above, I have determined the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 34-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  Two physician reviewers found that this patient did not appear to be in acute distress upon presentation to the emergency department. Her temperature was only slightly elevated at 99.3 degrees and other vital signs were within normal range. However, at the time the patient sought these services there had been recent outbreaks of the H1NI influenza virus and individuals with persistent flu-like symptoms were being advised to seek immediate evaluation. In fact, this patient states that she was advised by a family physician to go to the emergency department for H1N1 testing. Given these circumstances, a prudent layperson would reasonable belief her symptoms were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place her health in serious jeopardy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for (1) 15 hours per week of community applied behavior analysis (ABA) services, and (2) five hours per week of in-home with parent consultation ABA services. Findings:  The physician reviewer found that Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that the essential components of an individualized ABA treatment plan include a comprehensive evaluation to inform treatment goals, data based decision making, and establishing a learning environment that is conducive to treatment and that minimizes maladaptive behavior. In this case, the records note that the community setting is not conducive to the treatment of this patient due to significant maladaptive behaviors observed in the community setting. The patient is to be evaluated in the in-home setting to inform treatment modifications that would allow the patient to gradually resume treatment in a community setting. In this clinical setting, given that the providers recommendation against a community setting appears to be within established ABA guidelines, (1) 15 hours per week of community ABA services are not medically indicated. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and that they should be rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the home is currently the least restrictive environment that is appropriate for the delivery of ABA services. Therefore, (2) five hours per week of in-home with parent consultation ABA services are medically necessary to treat the patients condition to correct or ameliorate any physical or behavioral conditions. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology 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 a consultation with an orthopedic surgeon who specializes in hand and wrist surgery in adults for evaluation of the enrollees chronic bilateral wrist pain.Findings: The physician reviewer found that evidence based medical peer reviewed literature recommends surgical consultation for patients who fail to respond to nonsurgical management or have clear clinical and special study evidence of a lesion that has been shown to benefit, in both the short and long term, from surgical intervention. Current evidence based peer reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. This patient presents with worsening bilateral wrist pain and hand numbness. Significant impairment is reported in activities of daily living and work ability. Signs and symptoms, clinical examination findings, and imaging are noted and are consistent with carpal tunnel syndrome. Records documented conservative treatment to include anti-inflammatory medications, activity modification, and wrist splinting. He had been under treatment with an orthopedic surgeon in September 2017 who had recommended treatment to include injection therapy and electrodiagnostic studies, which have not been completed. Current evidence based medical guidelines and literature support specialty referrals for this patient based on persistent and worsening symptoms and documented failure of conservative treatment. Therefore, a referral to an orthopedic surgeon who specializes in hand and wrist surgery in adults is medically necessary for the evaluation of this patients medical condition.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

A male enrollee requested a 24-week course of Harvoni 90/400 mg for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, patients with advanced fibrosis or cirrhosis in whom a previous sofosbuvir-containing regimen has failed should be treated with daily Harvoni with or without ribavirin for 24 weeks. This is based on studies, such as the randomized COSMOS trial, in which sofosbuvir resistance-associated variants were not observed (Lawitz, et al). In addition, high rates of sustained virologic response have been observed with Harvoni treatment in patients with prior failure of Sovaldi and ribavirin (Osinusi, et al). Based on clinical literature and clinical guidelines, Harvoni for 24 weeks is medically necessary for patients with sofosbuvir failure, such as this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage of PTNS (percutaneous tibial nerve stimulation) treatments from 11/14/14 forward.Findings:  Two physician reviewers found that the patient has a history of intractable overactive bladder. This patient has tried numerous medications, including anticholinergics, but severe side effects were noted. Prior treatments were not tolerated. Subsequently, the patient tried beta agonist therapy without any improvement in her symptoms. She did have significant relief from percutaneous tibial nerve stimulation therapy. Her symptoms have almost completely subsided. The patient has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 11/14/14 forward. There is sufficient support for the services at issue in this patients case.  Intractable lower urinary tract symptoms related to overactive bladder can be clinically difficult to treat. Treatment options often have significant side effects and are not tolerable. Therefore, most often this is a multimodal treatment with proceeding to secondary and tertiary treatment options. PTNS is considered as a tertiary treatment option for intractable overactive bladder with urgency frequency syndrome. Furthermore, the records show that this patient has responded positively with this treatment.Final Result: Two reviewers determined that the services at issue were and are likely to be more beneficial for treatment 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 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 reimbursement and prospective authorization and coverage for continued skilled nursing facility level of care after completion of chemotherapy for treatment of the enrollees malignant neoplasm of the breast. Findings:  The physician reviewer found that the patient had nausea and extreme vertigo. She remained at risk for secondary complications of immobility such as pressure ulcers and contractures. She was participating in the treatments being provided and continued to require hands on assistance when ambulating and was not consistently ambulating household distances. The patient had previously been able to function independently. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care requested. As such, continued SNF level care was and is medically necessary for treatment of the patients medical condition. The reviewer determined that the services at issue were and 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent 200 mg/1.14 mL syringe, 2 syringes/28 days. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of patients aged six years and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Boguniewicz and colleagues note that moderate-to-severe atopic dermatitis is defined as involving over 10% of BSA and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and is not recommended for younger children. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has severe, wide-spread atopic dermatitis. The patient has tried and failed topical steroids and Protopic. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent 200 mg/1.14 mL syringe, 2 syringes/28 days, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 Otezla tablets. The submitted documentation supports the medical necessity of the requested medication. Otezla is used to treat psoriasis and is consistent with standards of care. The requested medication is U.S. Food and Drug Administration (FDA) approved for this indication and is considered safe. According to a study, apremilast (Otezla) is effective for the treatment of psoriasis. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Otezla tablets are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 66-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Three physician reviewers found that this patient only showed a limited response to the TMS treatments as evidenced by the fact that her BDI score remained in the severe range following therapy. In addition, the evaluation notes are inadequate to establish that other factors which could have adversely affected the prognosis had been ruled out prior to initiation of TMS. There are some notations considering the diagnosis of bipolar disorder, which has not been shown to be responsive to TMS as noted in studies in the earlier part of this decade (Kaptsan, et al. and Nahas, et al). This patients records do not indicate that she has ever undergone a course of electroconvulsive therapy (ECT), which the American Psychiatric Association (APA) treatment guidelines support as the most effective treatment for depression. Further, a recent controlled study published in 2007 conducted by Eranti and colleagues corroborate these findings. Overall, the APA guidelines suggest that treatment resistance may be a negative prognosticator for treatment with TMS. Moreover, Lam and colleagues meta-analysis concluded that additional studies are needed before TMS can be established as effective in the treatment of refractory depression. Similarly, Martin and colleagues found that the evidence supporting the efficacy of TMS remains inconclusive. In this particular instance, the patient exhibited some response to TMS treatment and reported having a partial response to Vivactil in the past. All told, the current peer reviewed research does not establish that TMS is superior to, or even the equivalent of, standard, accepted therapies. Considering this patients history as presented in the records provided for review, it cannot be established that a re-challenge with Vivactil, a trial of an MAOI or a course of ECT would not have been more effective than the TMS treatments provided in the management of her condition.