Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old male enrollee has requested  past cognitive therapy for treatment of the patient's autism.  Findings:  Two physician reviewers found that the patient has been assessed with autism. The patient receives multiple therapies. His primary physician recommended speech therapy, occupational therapy and physical therapy one to two times per week. An evaluation was performed for hippotherapy (cognitive therapy) and a treatment plan included improvement of coordination, improvement of body awareness, improvement of motor planning, and improvement of balance among other goals. At issue is whether the patients hippotherapy was likely to be more beneficial than any standard available therapy. While hippotherapy does show some efficacy for certain diagnoses, there is no convincing scientific evidence of its utility in autism. In fact, there is no mention of hippotherapy in the evidence-based review of interventions for autism used in or of relevance to occupational therapy (Case-Smith and Arbesman). Autism is mentioned as a diagnosis for which hippotherapy is useful, but references from the Reports of the International Therapeutic Riding Congresses offer little scientific investigation or evidence to support this conclusion. Some studies have demonstrated mild improvements in terms of communication skills, imitation, and perceptual and motor adjustment but were not performed under strict scientific methodologies (Hameury, et al. and Taylor, et al.). Some of these effects were sustained for a short period of time.  While promising, these studies do not provide significant evidence of long-term improvement in individuals with autism. Another study investigated the effectiveness of a simulated horse riding program on the motor proficiency and sensory integrative functions in 60 children with autism (Wuang, et al.). Investigators demonstrated that children with autism showed improved motor proficiency and sensory integrative functions after a 20 week program; however, this study was not performed using live animals and as a result, there could be generalizability issues. While the use of hippotherapy for patients with autism shows some promise, at this time hippotherapy cannot be considered more effective than standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for 12 weeks. Findings:  The physician reviewer found that according to the 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 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials. Additionally, 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 ENDURANCE-1 trial showed that only eight weeks of treatment is needed, not 12 weeks.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Mavyret for 12 weeks to treat hepatitis C infection is not medically necessary. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested authorization and coverage for a Nutropin AQ Nuspin for treatment of the enrollees medical condition. Findings:  The physician reviewer found that Based on the records provided for review, this patients presentation is not consistent with idiopathic short stature. A bone age reading of 14 years does not correspond to the described physical examination. The patients bone age was reported as markedly advanced versus his chronological age, despite a physical examination that documents early pubertal development. Using a reading of 14 years, the adult predicted height is 65.5 inches compared to the genetic target of 69.5 inches, which is statistically normal for the patients predicted range of +/- 4 inches. In addition, the patients IGF-1 was 238, which is -0.3 standard deviations for age and gender. Given these findings, GH therapy is not indicated and is not likely to be effective. From the available data, this patient has exogenous obesity, but not idiopathic short stature. Thus, the requested Nutropin AQ Nuspin is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 29-year-old male enrollee has requested intrapulmonary percussive ventilation machine (IPV) for treatment of his muscular dystrophy. Findings:  Two physician reviewers found that one use of the IPV machine is to help clear respiratory secretions in a patient with a poor cough from Duchenne muscular dystrophy. However, since this patient is on mechanical ventilation and has a tracheostomy, respiratory secretions are cleared with suctioning as needed via the tracheostomy and the IPV is not indicated. The records indicate this patient has had the current IPV machine. However, there is no documentation supporting the need for an IPV with mechanical ventilation and a tracheostomy. Further, there is a paucity of data demonstrating improved long-term health outcomes using an IPV in this clinical setting. Accordingly, the requested IPV machine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has sclerotherapy for the treatment of her varicose veins. Findings:  Three physician reviewers found that sclerotherapy is indicated as an adjunctive therapy when performed either at the same time as ligation or for treatment of residual or recurrent symptomatic varicose tributaries following prior surgical ligation and stripping, endoluminal radiofrequency/laser ablation. Based upon the evidence provided, ligation is not being performed at this time. In light of the Doppler finding, sclerotherapy alone is not likely to be effective and is not clinically indicated
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injections in both knees are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Benlysta injections for medical treatment of her systemic lupus erythematosus (SLE).   Findings:  The physician reviewer found that since approval, Benlysta has been demonstrated to be useful in the treatment of arthralgias and fatigue. Moreover, Benlysta has been shown to increase the interval between lupus flares. This patient continues to experience severe arthralgias and myalgias, failed methotrexate, and has been unable to tolerate hydroxychloroquine. Benlysta is therefore reasonable and medically necessary treatment for this patients disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, Platelet Rich Plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed various other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, the requested Monovisc injection in both knees is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient did not receive emergency medical services during the dates of service at issue. In this case, the IOP services were not emergency medical services as the medical records do not show that an emergency existed. The patient presented with depression and anxiety. There was no evidence that the patient was at risk of self-harm or presented with active medical problems or severe psychiatric symptoms. In sum, the services at issue were not emergent in nature. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Annovera. Kerns and Darney note, Combined (estrogen-progestin) hormonal contraception is available as an oral pill, transdermal patch, or vaginal ring and is highly effective when used consistently and correctly. Commonly available combined hormonal contraceptive rings include the etonogestrel/ethinyl estradiol ring (NuvaRing) and the segesterone acetate/ethinyl estradiol ring (Annovera). The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but have the advantage that daily or weekly user compliance is not required.` The U.S. Food and Drug Administration (FDA) notes that dosage for both the NuvaRing and Annovera systems are continuous for three weeks, followed by a one-week system-free interval. There is a lack of evidence in current medical literature supporting differences between the two systems in terms of weight gain, acne, mood changes, or efficacy in pregnancy prevention. Given that the patient reported significant side-effects with NuvaRing, another ring system is not medically indicated. Therefore, Annovera is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 58-year-old male enrollee has requested LASIK surgery for the treatment of his medical condition. Findings:  The physician reviewer found that the inability to feel glasses sitting on half of the face should not impact the ability to maintain them in a reasonable position.  The patient can still use his right hand to feel the position of the glasses on his face, he can use a mirror, and he can obtain snug fitting frames that do not shift.  Alternately, an elastic strap can be worn on the ear pieces to hold the glasses in place, or contact lenses could be utilized.  The prescription is devoid of any astigmatism, where a slight shift in position would more likely impact the quality of vision or visual comfort.
Appeal type: Medical Necessity
Decision: Overturned

The representative of an 18-year-old male enrollee has requested residential treatment for the treatment of the enrollees chemical dependencies. Findings:  The physician reviewer found that while the patient does not appear to be actively suicidal, homicidal or psychotic, he is a seriously ill young man who has become therapeutically engaged at his current residential treatment facility. Disrupting his treatment and transferring him to another facility for less intensive treatment is not in the patients best medical interests at this time. Discharging this patient is likely to be disruptive to his course of treatment and is potentially dangerous.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old male enrollee has requested Enbrel (etanercept) for treatment of his psoriatic arthritis. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be superior over other available treatment options.  The patient had a positive response to nonsteroidal anti-inflammatory medications in the past, and he has not had an adequate trial of conventional non-biologic disease-modifying antirheumatic drugs.  Treatment guidelines recommend nonsteroidal anti-inflammatory medications as a first-line treatment with non-biologic disease-modifying antirheumatic drugs as a second-line treatment.  If the number of joints found to be swollen on examination continues to grow or fails to respond to these medications, then a biologic disease-modifying antirheumatic drug such as Enbrel may be appropriate.  Therefore, Enbrel is not likely to be of greater benefit than other treatment alternatives in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested Lovaza (1gm per day) for treatment of her hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. The patient has a history of dyslipidemia that does not include significant hypertriglyceridemia, which is more than 200mg/dl. Current guidelines for the diagnosis and treatment of dyslipidemia do not recommend medication treatment for the patients reported triglyceride levels (Greenland et al). The American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines consider Lovaza reasonable only as an adjunct to diet therapy in the treatment of significant hypertriglyceridemia that exceeds 500mg/dl; this is the only U.S. Food and Drug Administration (FDA) approved indication for Lovaza. Moreover, there is a lack of evidenced-based clinical trials that demonstrate significant cardiac outcome improvement using Lovaza in this setting (Rizos et al). Thus, the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested heat treatment of varicose veins (endoluminal ablation of varicose veins  CPT code 36478) for treatment of her bilateral lower extremity painful varicose veins.  Findings:  Two physician reviewers found the treatment of perforating veins remains controversial as the recurrence rates are relatively high. The use of perforator directed treatments are generally reserved for patients with ulceration refractory to conservative measures. However, this patients records do not demonstrate that the patient has exhausted conservative treatment for her current complaints or that there is ulceration that has not responded to adequate treatment. Therefore, the medical literature does not support heat treatment of varicose veins with endoluminal ablation as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1 patients who have failed interferon and ribavirin 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. The guidelines also recommend Viekira Pak, although ribavirin needs to be used for genotype 1a and not genotype 1b. However, in this case, the laboratory testing could not differentiate. In addition, AASLD guidelines cite data showing decreased survival with delayed treatment. Treatment is required, and none has been approved.  For these reasons, the requested treatment with Harvoni 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: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for adolescent mental health residential (lock-down) treatment.  Findings:  The physician reviewer found that based on review of the available records, this patient was admitted to the residential treatment facility because of violent behavior and homicidal ideation expressed toward his parents. He reportedly grabbed the steering wheel of a vehicle while his father was driving. However, consistent with the medical literature, this patient does not appear to require 24-hour supervision and medical management as would be provided in a residential treatment facility. On evaluation, the patient was noted to not have any suicidal or homicidal ideation, hallucinations, or delusions, and presented with a coherent and linear thought process. Thus, applying the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) treatment guidelines, the patient does not meet the criteria for a residential treatment facility but rather an intensive outpatient treatment (IOP). Therefore, the requested mental health residential treatment level of care has not been established as medically necessary in this patients care.