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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL syringe to every four (4) weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has disease symptoms consistent with active disease while taking Stelara every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory testing results reported a low Stelara level of 0.3 ug/mL. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL syringe to every four (4) weeks is medically necessary 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: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a shingles vaccine due to the fact that she has a family member with shingles.  Findings:  The physician reviewer found that the Food and Drug Administration (FDA) approved indication for Zostavax is for the prevention of herpes zoster (shingles) in individuals 60 years of age and older. This is consistent with the recommendations published by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). In addition, a review of the medical literature reveals that Zostavax has not been studied in patients younger than 60 years of age and there are no recommendations for use in this patient subset. As the patient does not meet approved clinical indications for shingles prevention, the requested therapy is not medically indicated or necessary.
Appeal type: Urgent Care
Decision: Overturned

A 20-year-old female enrollee has requested for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that the review of the documentation, a prudent layperson would have sought immediate medical attention due to the pain, discomfort and uncontrolled urinary bleeding that this patient was experiencing. Her symptoms of dysuria, urinary frequency, urinary hesitancy, and gross hematuria were consistent with a urinary tract infection, cystitis, pyelonephritis, renal lithiasis, and other disorders which could result in serious impairment of the renal system, dysfunction of the urinary system, and could possibly place the patients health in serious jeopardy. A prudent layperson with this patients symptoms would reasonably expect that the absence of immediate medical attention could result in a serious health risk.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: In cases such as this an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The patient had some risk of harm (score 2) due to the patients history of a suicidal ideation that was noted in the progress notes. The patient demonstrated moderate functional status (score 3) as the patient has had deterioration and expected level of functioning in relationships with peers, adults and family. The patient has minor co-morbidities (score 2) as he was noted to have cannabis use in remission and does not have active serious medical problems. The patients recovery environment was mildly stressful (score 2) as the patient has issues with family relationships but has a stable housing situation. The patients recovery environment is supportive (score 2) as his family actively participates in treatment. The patient has demonstrated equivocal response to treatment (score 3) due to recent lack of progress in his IOP. The patient has been obstructive in treatment (score 3) as he inconsistently participates in therapy. The patients parents have been constructive (score 2) as they work actively and constructively with providers. This gives the patient presentation a composite score of 19 which correlates with IOP services. In summary, the IOP services were and are medically necessary for treatment of this patients behavioral health issues. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: 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. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 58-year-old male enrollee has requested authorization and coverage for Optune treatment for treatment of the enrollees glioblastoma multiforme.  Findings:  The physician reviewer found that Central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide. Most glioblastoma multiforme tumors recur, and then the treatment options are limited. This patient has exhausted these options.  Optune treatment was approved by the U.S. Food and Drug Administration (FDA) for the treatment of recurrent glioblastoma multiforme. Recently, the FDA expanded the indication for Optune treatment to include newly diagnosed glioblastoma multiforme when used along with temozolomide and radiation therapy. There is sufficient medical evidence to demonstrate the safety of Optune treatment. Thus, the requested Optune treatment is likely to be superior over other available treatment alternatives.  Final Result: Two of three reviewers determined that the requested services 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 21-year-old female enrollee has requested for continuing intensive outpatient program (IOP) services for eating disorders.  Findings:  The physician reviewer found that her need for continued care should be reviewed at least monthly.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old male has requested Sutent for treatment of acute myeloid leukemia (AML).  Findings:  Two physician reviewers found that Sutent, a multi-targeted tyrosine kinase inhibitor, has shown activity in a number of solid tumors, especially advanced renal cell carcinoma (RCC) and gastrointestinal stromal tumors (GIST), for which it is FDA approved. Sutent has been studied in AML. There is no standard therapy for AML. Many patients with AML have mutations in FLT3, a tyrosine kinase that Sutent can inhibit.This patient has clearly responded, with reduction in his blast count and should continue on this therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy, at a frequency of two times per week for treatment of the enrollees receptive and expressive language delay.  Findings:  The physician reviewer found that the current medical evidence supports the requested therapy in this patients case.  Per Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors reported that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, he demonstrates receptive and expressive language delay that is negatively impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in such children.  All told, speech therapy, at a frequency of two times per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested for Lexapro 20 mg for treatment of her behavioral health condition.  Findings:  The physician reviewer found that Davidson and colleagues indicate that Lexapro (escitalopram) has been shown in clinical trials to be efficacious in decreasing symptoms of anxiety associated with panic disorder and other anxiety disorders. Also, the article by Dougherty and colleagues indicate that Lexapro may provide superior reduction in obsessive compulsive disorder (OCD) symptoms for patients who have co-morbid depression and anxiety. Therefore, the literature supports efficacy and tolerability in using Lexapro for anxiety disorders and even the off-label use of FDA-approved medications is a common practice. In conclusion, this patient has demonstrated a positive response to Lexapro following failed attempts at the use of other psychotropic medications to treat her symptoms from depression and anxiety, and the literature supports efficacy of Lexapro for anxiety
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested for low back fusion surgery for treatment of herlow back pain. Findings:  The physician reviewer found that the patients MRI scan findings have not demonstrated any focal changes which may reasonably be addressed with surgical intervention. In addition, the efficacy of decompression surgery has been reviewed and the study authored by Osterman and colleagues showed that there were no clinically significant differences between patients who underwent decompression surgery versus those treated with conservative management over a two-year follow-up. The study authored by Puel and colleagues did demonstrate a short-term benefit for patients leg pain. However, the patient population in these studies does not appear to match the clinical presentation of  this patient, in that the anatomical studies do not reveal localized focal disc herniation, but rather mild neural foraminal narrowing. The large disc fragment described anterior to the vertebra at L5-S1 level is not likely relevant to the patients lower extremity pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 38 hours per week of direct applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 38 hours per week of direct ABA services medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting ABA as a medically necessary for the treatment of children with autism. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the records indicate the patient was previously making excellent progress at the frequency of 38 hours per week of ABA. Moreover, a decrease in the weekly ABA hours will make it difficult for the patient to make progress towards his 44 ABA goals. Final Result: The reviewer determined that that 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for interferon alfa-2B recombinant 1 M U injections, (30 units, three times per week). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees extra skeletal Ewing sarcoma/peripheral primitive neuroectodermal tumor.Findings:  The current medical literature does not consider interferon alfa-2B a standard of care for patients with skeletal Ewing sarcoma/peripheral primitive neuroectodermal tumor. It is not supported by off label use by major drug compendia or the National Comprehensive Cancer Network guidelines. The abstract provided for review is from 1999 and in discussed patients with osteosarcoma. In addition, there are other standard therapies available to this patient as well as clinical trials that involve newer drugs that are less toxic and more promising according to medical literature. Accordingly, interferon alfa-2B recombinant 1 M U injections, (30 units, three times per week) is not likely to be more beneficial than any available standard therapy for treating this patients medical condition.Final Result: Two of the three reviewers determined that the medication is 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the left knee. Findings:  The physician reviewer found that the evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. Campos and colleagues concluded that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. However, viscosupplementation was not superior to the use of a corticosteroid injection. In their randomized controlled trial, Di Martino and colleagues found that the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction. This patient is status post left knee ACL reconstruction with allograft, partial medial and lateral meniscectomy, and arthroscopy with debridement and chondroplasty, synovectomy, and partial meniscectomies. The patient underwent pre-operative cortisone injections, which did not help. She presented with a moderate effusion and underwent aspiration of fluid. There is no documentation of the patients response to aspiration, lab results, or failure of a post-operative cortisone injection. There is no current crepitus or tenderness to palpation. Therefore, Orthovisc injections in the left knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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 patient is a 44-year-old male who has a body mass index (BMI) of 45.6. In addition, the patient has several comorbid conditions including sleep apnea, degenerative arthritis, and gastroesophageal reflux disease. There is no evidence that the patient has undergone a psychiatric consultation. A request has been made for gastric bypass surgery. The Health Plan has denied the request on the basis that gastric bypass surgery is not medically necessary.With a BMI of 45.6 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether he is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the procedure should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic arterial embolization. Findings:  The physician reviewer found that the patient is with over a decade  year history of benign prostatic hyperplasia (BPH).  He presented to his provider with symptoms of urgency, frequency, weak stream, difficulty voiding and nocturia.  The patient has requested coverage for prostatic artery embolization to treat his BPH. The Health Plan has denied this request. Per the Health Plan, prostatic artery embolization is considered investigational for treatment of this patient. The medical literature does not show that prostatic artery embolization provides the same degree of improvement when compared to transurethral resection of the prostate or laser ablation of the prostate in patients with BPH. The embolization procedure appears to have a higher degree of urinary retention in the post procedure period, and there are irritative symptoms that persist for months after the procedure.  At this point in time, there are not enough studies to suggest that embolization is as efficacious as other more accepted forms of treatment for BPH. All told, prostatic arterial embolization is not likely to be more beneficial than other standard therapies for the treatment of this patient. Final Result: The reviewers determined that the requested services 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: Physician reviewers 1, 2 & 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.