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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Trokendi XR for treatment of her medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Topiramate is indicated for migraine prevention, and has evidence for being effective for chronic migraine. However, there are a variety of common side effects with topiramate, including paresthesia, fatigue, and cognitive changes. Trokendi is an extended release formulation of topiramate.  Trokendi has been shown to be favorable in terms of side-effects compared to immediate release topiramate. In this case, the patient has been treated with Topamax (topiramate) and it was discontinued due to side-effects. There is a lack of documentation provided demonstrating that Topamax had been beneficial, even at higher doses. Moreover, Botox which has been recommended by the provider is indicated for chronic migraine, with good data regarding effectiveness and tolerability. Botox is reasonably appropriate and likely to have superior results compared to topiramate, which she has previously tried. Therefore, the request for Trokendi XR is not medically necessary.  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 Physician reviewer is board certified in neurology 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 Avastin in combination with chemotherapy for treatment of her medical condition. Findings: Two physician reviewers found that Avastin has been approved for use, along with chemotherapy, in several types of cancer. It has demonstrated some activity in uterine cancer.  Lorusso and colleagues compared results in patients who had had prior treatment, with chemotherapy alone or chemotherapy with Avastin.  The combination did demonstrate a higher response rate and progression free survival, but no significant difference in overall survival. At this time, there is a lack of convincing data as to the clinical benefit from adding Avastin to chemotherapy in this clinical setting.  All told, Avastin in combination with chemotherapy is not likely to be of greater benefit than other treatment options in this patients case.  Final Result: Two reviewers determined that the requested 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for testosterone cypionate (200 mg/mL x 12-30DS). The records provided for review document that this patient has a history of hypogonadism complicated by obstructive sleep apnea (OSA). The patients provider states that treatment with continuous positive airway pressure (CPAP) has been effective in improving the patients OSA, but the patient's testosterone levels remain low. The provider has recommended continued treatment with testosterone cypionate since it has been beneficial for the patient. Testosterone deficiency can be asymptomatic or lead to a broad spectrum of symptoms ranging from sexual symptoms to nonspecific symptoms, such as fatigue, depression, poor concentration, altered body composition with more body fat and decreased muscle mass, and lower bone mineral density (Ide, et al.). The mainstay of a diagnosis of hypogonadism includes the presence of signs and symptoms consistent with hypogonadism coupled with low morning serum testosterone levels on two or more occasions (Salonia, et al.). The management of testosterone deficiency aims to induce and maintain secondary sex characteristics and correct symptoms of testosterone deficiency. The potential benefits of therapy include increased libido, improved sexual function, improved mood and well-being, and increased muscle mass and bone density (Petering, et al.). In this case, the patients records support a diagnosis of hypogonadism that has responded well to treatment with testosterone cypionate. For these reasons, the requested testosterone cypionate (200 mg/mL x 12-30DS) is medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for bilateral mastectomy and nipple reconstruction. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Researchers reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient had gender dysphoria, had spent ample time living in the desired gender role, and had one year of testosterone treatment. The patients providers reported that the services at issue were medically indicated for the treatment of this patient. Therefore, bilateral mastectomy and nipple reconstruction were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 parent of a 17-year-old male enrollee has requested direct applied behavioral analysis (ABA) services and 2 hours per week of supervision for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient is an adolescent who was identified as autistic at the age of 2 and has been the recipient of ABA therapy for several years. The patient has also been diagnosed with generalized anxiety disorder. The submitted clinical records do not demonstrate that the patient has shown a significant response to ABA therapy. The patient continues to present with aggression and maladaptive behaviors and has shown regression of previously acquired self-help skills. There is a lack of adequate evidence in the peer-reviewed literature to support the clinical effectiveness of ABA in the adolescent autistic population, particularly where there is marked regression and re-emergence of marked problematic behaviors. Therefore, considering the best available evidence in relation to this patients individual circumstances, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested speech therapy, at a frequency of two times per week, and occupational therapy, at a frequency of one hour per week for treatment of the enrollees motor hypotonia and expressive speech and language developmental delay.  Findings:  The physician reviewer found that this patient has multiple delays that impact her ability to function in an age-appropriate manner. She has difficulties with expressive language, self-care, fine and gross motor skills, and feeding skills. These difficulties are preventing her from acquiring the usual skills of childhood, and persistence can lead to difficulties navigating the educational system and interacting with peers. Successful feeding clinics incorporate the services of occupational therapy, speech therapy, and nutrition in treating patients. In addition to significant expressive language delay that merits speech and language therapy, this patient exhibits feeding issues that affect her ability to obtain adequate nutrition. Speech therapy is imperative to successful intervention.  Thus, the requested speech therapy, at a frequency of two times per week, is medically indicated.  In addition, with its focus on developing teaching self-help skills including feeding skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this case. Occupational therapy, at a frequency of one hour per week, is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the pelvis without dye. The diagnostic evaluation for defecatory dysfunction consists mainly of a history and physical examination. The examination includes assessment of the anatomy and confirmation of prolapse, evaluation of the perineal body and posterior vaginal wall, performance of a focused neurologic examination, and examination of the anal sphincter. The posterior vaginal wall and perineal body are best evaluated by rectovaginal examination. Since clinical examination is the main diagnostic modality for posterior vaginal defects, radiologic confirmation of the presence or absence of a rectocele is not recommended. There is a lack of standardization for establishing a radiological diagnosis of a rectocele. All told, the MRI of the pelvis without dye was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the MRI of the pelvis without dye was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 22-year-old male enrollee has requested  for acute inpatient psychiatric treatment services for treatment of the enrollees opiate dependence with physiologic dependence. Findings:  The physician reviewer found that there was no clear cut indication that he had a specific plan or that he had actively attempted suicide. He was not psychotic or overly aggressive. He was experiencing signs of opiate withdrawal and was clearly in some discomfort. However, the magnitude of his withdrawal did not specifically demand inpatient care. His need for 24/7 professional observation was not demonstrated. The patient did not present a serious risk of harm to self or others. His functioning was impaired but not seriously deteriorated. The patient could have been safely and effectively treated at a lesser level of service.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1a.  Findings: The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. 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. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the office visit and related services required on an emergent or urgent basis.  Findings:  The physician reviewer found that the patient presented with a concern for a recurrence of testicular cancer. The physical examination did not demonstrate a palpable mass. Moreover, an ultrasound is not indicated in the setting of a negative physical examination. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. The patient presented with a history of testicular cancer and presented to an out-of-network urologist due to testicular pain and a concern for a recurrence of cancer. In this clinical setting an urgent evaluation of the reported palpable lesion by an urologist was necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the he returned to the Health Plans service area. However, the patients physical examination was negative and the ultrasound performed was not necessary to prevent serious deterioration of the patients health resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Health Plans service area. Final Result: The reviewer determined that a portion of the services at issue were required on an urgent basis. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in urology 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 authorization and coverage for inpatient hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for inpatient hospitalization is not medically necessary for treatment of the patients medical condition. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of eating disorders. According to researchers, after inpatient weight restoration, CBT significantly reduced relapse risk and increased the likelihood of good outcomes compared with nutritional counseling, based on nutritional education and food exchanges. Without a specific medical complications or need for refeeding, inpatient admission is typically not recommended for treatment of eating disorders. According to other researchers, clinical practice guidelines recommend treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. In this case, the records do not demonstrate that the patient has medical complications that requires inpatient care. According to the documentation submitted for review, the patient was initially admitted to the inpatient program due to suicidal ideation. The patient also reported symptoms of depression and anxiety as well as eating disorder symptoms. The patients vital signs as well as weight and body mass index were all within normal limits. Her body mass index also remained within the normal range. The records demonstrate that the patient has eating disorder symptoms as it was noted that she was not eating 100% of the meals. However, despite not eating all of the meals the patients vital signs remained within normal limits. In addition, the records do not indicate what type of prior treatment the patient has had for the eating disorder for other psychiatric conditions. The records also do not indicate that the patient was exhibiting aggressive or dangerous behaviors towards self or others. The patient was noted to be uncooperative in group treatment but had agreed to take psychiatric medication as recommended by the provider. In sum, the patients symptoms do not support the need for inpatient care. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested Botox injections for the treatment of his back pain. Findings:  Three physician reviewers found that there have been several scientific studies to evaluate the utility of Botox. Currently, there is a lack of sufficient scientific evidence from randomized, controlled studies to demonstrate that Botox is likely to be more effective than alternative standard treatments for myofascial low back pain. A publication from Jeynes and Gauci reviews the literature on Botox for a variety of conditions. The authors note there is conflicting evidence with regard to the use of Botox for myofascial pain, such as is present in this patient. All told, the superiority of Botox in this particular setting has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee requested residential treatment center services for medical treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and bipolar disorder.  Findings:  The physician reviewer found that the weekly progress notes do not support the medical necessity of the RTC services provided to this patient. The patient was making progress and learning coping skills. Additionally, each weekly progress note documented that the patient had just completed a successful weekend pass with his family. The main issue for almost all the notes is that he became upset upon having to return to the facility after his pass. Only after was there mention of the patient requiring seclusion prompted by refusing to follow staff directions. There was no mention of his trying to harm himself or others. Based on the providers notes, the patient was stable for treatment at a less restrictive treatment setting. The patient could be safely and adequately treated with dialectical behavioral therapy (DBT) and medication management in this setting. Thus, the RTC services were not medically necessary for treatment of this patients medical condition.