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 Praluent (alirocumab) injections 75 mg/mL every two weeks. Findings:  The physician reviewer found that either ezetimibe or a proprotein convertase subtilisin-kexin type 9 (PCSK9) may be added to maximally tolerated statin therapy in patients with clinical ASCVD with comorbidities and baseline LDL-C over 70 mg/dL. The authors further note that considerations that may favor the initial choice of ezetimibe include patients who require less than 25% additional lowering of LDL-C, ease of use as an oral agent with low pill burden, patient preferences, and hypertension. In this case, the patient is noted to have persistent elevated liver enzymes. In this clinical setting, given that ezetimibe may worsen liver function, the requested medication is medically indicated. Therefore, Praluent (alirocumab) injections 75 mg/mL every two weeks 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 internal medicine withs sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a history of migraines successfully aborted with one to two Maxalt tablets. The submitted information documents a trial of only one preventive medication. The patient states she is able to control her migraines with two Maxalt tablets. She has requested authorization and coverage for 12 Maxalt tablets per month. The Health Plan has denied her request indicating that the requested quantity of Maxalt tablets is not medically indicated for treatment of the patients migraine headaches.The patients headache frequency warrants preventive agents. Such agents will likely reduce the patients headache frequency and severity as well as increase her response to Maxalt, thereby allowing her to take one tablet per headache instead of two. Patients such as this patient often benefit from preventive medications such as Topamax, Depakote, Neurontin, etc. The patient should be followed by a neurologist to identify a preventive medication that is effective. Thus, the Health Plans recommendation that the patient follow-up with a neurologist for consideration of prophylactic management is medically reasonable and appropriate. Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. However, the patient should receive 12 Maxalt tablets per month for a period of two to three months while preventive treatment is pursued.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization mental health treatment provided from 7/11/16 through 7/19/16.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this case, the patient had a serious addiction to alcohol which contributed to occupational problems, interpersonal discord, depression and dangerous behaviors such as operating a motor vehicle while intoxicated.  He had a history of alcohol withdrawal seizure activity.  He abused substances other than alcohol as well.  Upon presentation, he was depressed and irritable, and diagnosed with a mood disorder.  He failed two previous residential placements which suggested the need for a more conservative treatment course.  Thus, the partial hospital placement was indicated.  Per the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting by 7/11/16.  On 7/11/16, the patient was in the contemplative stage of change.  He was not active in all programmatic elements.  He was still craving alcohol.  He had not yet resumed naltrexone, an anti-craving medication.  Additionally, he had not yet established a sober network in the community.  Considering the patients clinical presentation, partial hospitalization was a safe, appropriate disposition consistent with good medical practice while the duration of services provided aligned with community standards of a case of this severity.  Final Result: The reviewers 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 physician 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neurological evaluation services rendered. Researchers report that, Early identification of dyslexia is crucial to ensure that children are able to maximize their educational potential. Researchers note that, Comprehensive intervention services for students with comorbid ADHD and learning disabilities will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings. Researchers observed that, Children with dyslexia often have related writing difficulties, but found that writing and even reading skills could be improved with instructional strategies in spelling, transcription, executive function, and working memory. In this case, the patient had a previous diagnosis of autism spectrum disorder, and has a current diagnosis of ADHD, dyslexia and dysgraphia. Given that the patient is now under medication management for ADHD, and has received recommendations for interventions to treat his dyslexia and dysgraphia, the services at issue were medically indicated in this clinical setting. Therefore, the neurological evaluation services rendered were medically necessary for the evaluation 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 neurology with special qualification in child 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 a cold therapy device for treatment of his medical condition. Findings: Three physician reviewers found that upon review of the operative note, some form of cryotherapy was appropriate in view of the extent of the surgical procedure. A further issue to be decided is whether cryotherapy has increased efficacy when administered through a mechanized pump versus the simplest form of cryotherapy in the form of icepacks and ice bags. In this case, medical evidence has not established the superior efficacy of the device at issue compared to simpler applications of cold.  The article by Martimbianco and colleagues provides support for reduction in pain levels at 48 hours, but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life.  The authors concluded that there is a need for additional studies with randomized trials before the ambiguity as to the efficacy of cryotherapy can be resolved. In the study authored by Raynor and colleagues, a meta-analysis of the use of cryotherapy following anterior cruciate ligament reconstruction was published; six studies were reviewed. Some individual studies reported significant benefit but a pooled analysis did not support a significant impact compared to traditional methods of delivering cold, such as icepacks. In summary, while cryotherapy was indicated and likely to have been beneficial for this patient, simpler applications of cold would have been equally efficacious. Therefore, the cooling device was not likely to be more beneficial than simpler applications and so, the superior effectiveness of the equipment at issue has not been established. Final Result: Three reviewers determined that the device at issue was 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 orthopedic surgery 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

The parents of a two-month-old premature female who has experienced recurrent syanotic episodes requiring admission to the neonatal intensive care unit are requesting authorization of Synagis.  Reviewers FindingsThe reviewing physician found that the patients gestational age places the patient at risk for severe respiratory syncytial virus.  The patient also has the additional risk factors that increase both morbidity and mortality.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested medical services and physical therapy for the treatment of her ulnar nerve inflammation of the left upper extremity and partial tear left rotator cuff. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the physical therapy. The evidence demonstrates that the patient improved with the physical therapy services she received previously. By the time the patient established care with the provider of the services in question, the therapy could have continued as a home exercise program. The patient had achieved maximum benefit from supervised therapy and based on standards of practice, had received a sufficient number of therapy sessions by the date in question. The patient reported that her pain was intermittent. Additionally, there is no evidence that physical therapy is beneficial for ulnar nerve inflammation; medications were likely to be more effective for this condition, but do not appear to have been implemented. With regard to the medical services performed, the evidence does not demonstrate that the manipulation therapy that was provided was effective or indicated. The notes do not document range of motion/strength/tenderness and provide no indication of any improvement from the services provided. Thus, there is no objective evidence that these services were medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve bocks every four weeks. In this case, the patient has been diagnosed with chronic migraines and occipital neuralgia, which have been refractory to medication management with multiple classes of agents. The provider noted that the patient underwent treatment with an occipital nerve block. The patient was reportedly satisfied with the results, but there is a lack of documentation of percentage of pain relief or duration of benefit. The provider has recommended treatment with serial repeat occipital nerve blocks every four weeks. However, the current evidence regarding the use of occipital nerve blocks is limited given the limited studies showing superiority to standard of care treatments. Barmherzig and Kingston found that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. Chowdhury and colleagues found that treatment with greater occipital nerve block was found to be safe and the treatment-emergent adverse effects (TEAEs) were generally mild and transient. The authors concluded that the long-term preventive efficacy of occipital nerve blocks needs to be assessed by further randomized controlled trials. Based on these findings, the requested occipital nerve bocks every four weeks are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is 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

A 22-year-old male enrollee requested substance abuse residential treatment center services (RTC) for medical treatment of his substance abuse. Findings:  The physician reviewer found that according to the documentation submitted for review, this patient represents a high risk for relapse. He required the high degree of structure of a 24-hour residential setting in order to help him start to build and solidify coping skills towards relapse prevention. The patient met American Society of Addiction Medicine (ASAM) placement criteria for residential level of care.  Subsequently, 30-minute checks were discontinued, he endorsed decreased auditory and visual hallucinations, and he was attending groups, demonstrating motivation for change. Thus, he could have been stepped down to a lower level of care. Therefore, residential treatment services provided initially were medically necessary for treatment of the patients medical condition and a portion of the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for labiaplasty. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient developed hypertrophy, hyperpigmentation and hyperkeratosis of her labia majora, with associated itching and irritation over an eight-month period.  This has all the signs of a dermatologic condition that may be allergic, irritant, or infectious in etiology.  This is not the typical history for labial hypertrophy, which generally refers to enlarged labia minora, not the labia majora.  The patient describes the labia as having more laxity, which would be more of a cosmetic issue.  She states she is having issues with keeping the labia clean, which would suggest that she may be cleaning or rubbing the tissue excessively, which could account for the hyperpigmentation and hyperkeratosis as well as the itching and irritation, a condition known as lichen simplex chronicus.  Surgery would not be the appropriate treatment for this condition, and healing could actually be impaired if surgery is done on her irritated tissue.  There are a number of treatments that could help resolve her symptoms, all of which are non-surgical.  Therefore, the requested labiaplasty is not medically necessary for the treatment of this patient. Based on the medical records, this patients condition does not constitute an abnormal structure of the body.  She has structurally normal, but irritated, labia majora.  This condition can be treated non-surgically.  The requested surgery will not improve function or create a normal appearance.  If the underlying dermatologic issue is treated, function and appearance are likely to improve.  Surgery is not appropriate for this condition.  Per the clinical documentation, the requested services will not offer more than a minimal improvement in the appearance of this patient.  In sum, the requested labiaplasty is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 seven-month-old female enrollee has requested for Synagis vaccine for treatment of the enrollees prematurity and respiratory distress due to transient tachypnea of newborn.  Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in infants born at 32-35 weeks gestation, up to 12 months of age. The most notable of these factors is a birth weight less than 2500 grams (Holman, et al). In addition, Horn and Smout analyzed retrospective data from 304 infants less than 1 year of age with bronchiolitis or RSV pneumonia admitted to the hospital. Data were subdivided by gestational age (less than 32 weeks, 33-35 weeks, and greater than 36 weeks) and compared, looking at rates of intubation and ICU admission, as well as length of stay. The authors found that infants less than 1 year of age born at 33-35 gestational age (GA) fared worse than those born more prematurely over all measures. Specifically, the authors concluded that, Premature birth during this critical period of lung development (32-35 weeks GA) may result in significant alteration in lung function and physiology. The IMpact-RSV Study Group evaluated the effect of palivizumab prophylaxis on severity of illness in premature infants and reported a significant decrease in hospitalization rate for all infants. For infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness, and is thus medically necessary for this patient for the 2011-12 RSV season.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old male who experienced head trauma as well as other injuries as the result of a fall from a ladder. The patient subsequently received acute inpatient care. The Health Plan has recommended transfer to a skilled nursing facility. The patients family has requested the patient be placed in a different facility for rehabilitation. The patient has made rapid improvement with physical therapy. He had continued need for speech therapy and may benefit from cognitive rehabilitation.The patient has made dramatic gains in the hospital without benefit of the acute rehabilitation structure. His medical and nursing needs can be addressed in a skilled nursing facility. Physical therapy, occupational therapy, and speech therapy can all be provided in a skilled nursing facility. The patient does not require extensive physical therapy, occupational therapy and speech therapy, but should have access to cognitive rehabilitation while receiving skilled nursing care. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline 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.  All told, Harvoni for 12 weeks is medically indicated 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 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.