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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. There was no evidence of post-acute withdrawal symptoms, or danger to self or others. She was cognitively intact and was not gravely disabled.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She was medically and psychiatrically stable to the extent that she did not need a 24 hour per day/seven day per week facility to render the remainder of her care.  Her medication regimen did not require a residential setting.  She had a history of an extended period of sobriety with Alcoholics Anonymous exposure.  She demonstrated insight and motivation. There was no evidence that she would relapse if returned to her home environment, which was sober and supportive.  She could have been stepped down to an ambulatory level of care at that point, such as intensive outpatient services. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old female enrollee has requested for Genotropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the scientific literature does not demonstrate that Genotropin is associated with better outcomes, fewer side effects or confers added benefit among this patient population as compared to the Health Plan formulary alternatives. Nor is there evidence that Humatrope and Nutropin are contraindicated for use by this patient. All told, the alternative medications offered by the Health Plan are medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for the treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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 non-cirrhotic genotype 1 patients should be treated with Harvoni.  For these reasons, the requested treatment with Harvoni is 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services at issue were not and are not medically necessary for treatment of the patients behavioral health condition. Per the Health Plans clinical documentation, the patient is not psychotic, suicidal, or homicidal. The submitted documentation indicates that the patient has insight and judgment and is not delusional, and he does not have symptoms of withdrawals that require 24-hour supervision. Given the above, the medical necessity of the services at issue has not been established.  Final Result: The reviewer determined that the services at issue were not and 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for Stelara 90 mg every four (4) weeks. Findings:  The physician reviewer found that current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for six months. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, and the other medications. A 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 symptoms and colonoscopy findings consistent with active Crohns disease on Stelara. The patient has failed multiple biologic and conventional alternatives, and had disease symptoms on Stelara every eight weeks. Use of Stelara every eight weeks or a change to another medication may result in worsening disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every four weeks is medically necessary for treatment of the patients Crohns disease.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 subspecialty 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 16-year-old male enrollee has requested for residential treatment services for treatment of the enrollees attention-deficit/hyperactivity disorder, oppositional defiant disorder and marijuana abuse. Findings:  The physician reviewer found that there is no indication that the patient demonstrated much beyond a personality construct of significant narcissism, with relatively minor outward behavioral manifestations at that.As such, there are no medical grounds for continued residential treatment beyond this point.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic gastric restrictive procedure with gastric bypass with Roux-en-Y gastroenterostomy. Findings:  The physician reviewer found that records document a history of prior laparoscopic sleeve gastrectomy with current complaints of gastroesophageal reflux disease (GERD) despite treatment with a proton pump inhibitor (PPI). However, the records do not demonstrate that the patient has undergone an adequate PPI trial length, or that the patients dietary and lifestyle factors are not contributing to her GERD symptoms. The patients current BMI is 29 kg/m2. The esophagogastroduodenoscopy (EGD) report was from a few years ago, prior to the patients sleeve gastrectomy. An upper gastrointestinal series revealed normal sleeve anatomy and a tiny sliding hiatal hernia without mention of GERD. The records do not include a recent dietary or behavioral evaluation. Furthermore, there is a lack of recent EGD or 24-hour pH study documenting GERD. Overall, there is insufficient evidence to support the medical necessity of the requested conversion to gastric bypass procedure. All told, the requested laparoscopic gastric restrictive procedure with gastric bypass with Roux-en-Y gastroenterostomy is not medically necessary for treatment of this patient.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 general surgery with expertise in advanced minimally invasive surgery and bariatric 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an intraoral device for treatment of his obstructive sleep apnea (OSA).   Findings:  The physician reviewer found that the records in this case indicate that the patient carries a diagnosis of OSA. The records do not indicate any significant medical changes that would contribute to the amelioration or resolution of sleep disordered breathing such as surgical intervention or significant weight loss. In addition, the records indicate the patients body mass index (BMI) is not reflective of obesity. Current practice guidelines form the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) support the use of oral appliance therapy in patients with mild or moderate OSA who are intolerant of or decline CPAP (Ramar, et al). As a result, the provision of an oral appliance in this case would be within the currently accepted standards of medical practice for the treatment of OSA. Accordingly, the intraoral device provided to this patient for the treatment of OSA is supported as medically necessary.  Final Result:  The reviewer determined that the device at issue was 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 sleep medicine and 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: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested weekly individual psychotherapy sessions for at least one year for treatment of her major depression.  Findings:  The physician reviewer found that the provider offered a short-course of time limited psychotherapy not stating that it was clinically recommended or superior to individual therapy in this case. Cuijpers and colleagues identified that, at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. Based on review of the available records, a course of 18 weekly individual psychotherapy sessions, followed by a clinical reassessment of status, goals, needs and progress, and reappraisal of the treatment plan if indicated, is medically necessary for the treatment of this patients major depressive disorder.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni 90/400 mg for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that the patient has chronic hepatitis C and has an advanced stage disease.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Hence, per the national guidelines, this patient should be treated urgently with Harvoni.  All told, Harvoni 90/400 mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old male enrollee has requested circumcision for the enrollee who is uncircumcised. Findings:  The physician reviewer found that circumcision outside of the neonatal period is medically necessary for structural or functional abnormalities. In the normal developing child without abnormality or disease, circumcision is not necessary from a medical standpoint. Singh-Grewal and colleagues acknowledge in their publication that the potential risk of illness or disease in the uncircumcised male has been the subject of much debate. One such risk is that of urinary tract infection (UTI). While the risk of UTI is higher during the first year of life in uncircumcised male infants, this heightened risk does not apply to this patient who is three years of age. Grewal and colleagues conclude The data we present do not support the routine circumcision of normal boys with standard risk in order to prevent UTI.  Furthermore, there is no evidence that the failure to circumcise in this setting presents greater risk to the patient than the risk associated with the procedure itself; circumcision outside the neonatal period often involves the use of general anesthesia and requires a more formal surgical procedure with hemostatis and suturing of skin edges.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly mental health therapy visits for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is no defined frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect.  Given this information, the patient has had extensive mental health treatment in the past. The patient starting seeing a non-Plan psychotherapist. Per the documentation, the patient reported in an email that the non-Plan provider cannot see the need for weekly sessions. Based on the submitted documentation, the patient was stable. He has been sober for over six months. He did not have any suicidal ideation or homicidal ideation. The patient was working, sleeping well, and had improvement from his psychotherapy sessions. The records do not demonstrate that the patient requires weekly psychotherapy sessions. All told, weekly mental health therapy visits are not medically necessary for the treatment of this patient. 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 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 patient has requested authorization and coverage for Euflexxa injections in both knees. Findings:  The physician reviewer found that systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this patients case, there is a history of prior viscosupplementation which was greatly beneficial. The patient is attempting to delay or avoid bilateral total knee arthroplasties. Given these findings, the requested Euflexxa injections in both knees are medically necessary for treatment of this patient. 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: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage for 30 sessions of transcranial magnetic stimulation.  The Health Plan denied this request indicating that the requested services are considered investigational for treatment of the enrollees major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of depression.  The medical records do not note a history of comorbid substance abuse or dependence.  His past medical history is significant for obstructive sleep apnea with CPAP use.  There was no history of cardiac risk factors.  He has been diagnosed with major depressive disorder and dysthmia.  The patients prior medications included Deplin, Ativan, Prozac, Effexor, nortriptyline, Zoloft and Wellbutrin.  The medical records noted 10 electroconvulsive therapy treatments in the past.  Medical records noted good response to electroconvulsive therapy. However, more recent medical records noted that the patient did not do well with electroconvulsive therapy in the past.  The patient has requested authorization and coverage for 30 sessions of transcranial magnetic stimulation.  The Health Plan denied this request and reported that the requested services are investigational for the treatment of this patient. Augmentation strategies, such as mood stabilizers, atypical antipsychotic medications or use of stimulant medications, are likely to be of greater benefit than transcranial magnetic stimulation in this patients case. Additionally, per the submitted documentation, strategies such as cognitive behavioral therapy were not utilized.  These available treatment strategies are recommended for treatment-resistant patients, per American Psychiatric Association guidelines.  This patient has not received electroconvulsive therapy in the current episode of illness.  As noted in the medical documentation, electroconvulsive therapy was provided previously.  Transcranial magnetic stimulation therapy has not been demonstrated to be more beneficial than electroconvulsive therapy for the treatment of major depressive disorder.  In sum, the requested 30 sessions of transcranial magnetic stimulation are not likely to be more beneficial than other available treatment modalities. In this patients case, no additional transcranial magnetic stimulation treatments are likely to be more effective than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the Cartiva synthetic cartilage implant. Based on the current peer-reviewed medical literature, the Cartiva implant was not likely to be more beneficial for the treatment of the patients condition than any available standard therapy. Conventional therapies include joint fusion or standard implant. Due to the limited published data on the Cartiva device, including the short- and long-term benefits and potential side effects, the Cartiva synthetic cartilage implant was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Cartiva synthetic cartilage implant was 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 services at issue were 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 podiatry and is actively practicing. One Reviewer is board certified in podiatry and is actively practicing.  One Reviewer is board certified in podiatry 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral endoscopic lumbar sympathectomy surgery for treatment of her medical condition.  Findings:  Three physician reviewers found that according to the documentation submitted for review the patient presents with disabling plantar hyperhidrosis. She has tried and failed multiple medications and treatments. Sympathectomy is a surgical procedure involving clipping of the sympathetic chain of nerves which has been shown to reduce sweating.  Typically involving the thoracic sympathetic chain, this treatment is used to reduce hyperhidrosis of the hands.  This patient had relief of her symptoms involving the hands following this procedure, but continues to have disabling symptoms on her feet.  Treatment of the lumbar sympathetic chain would be expected to address those symptoms. As there is a lack of available standard therapeutic options available for this patient, lumbar sympathectomy for lower extremity hyperhidrosis is clinically indicated. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 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:   All three reviewers are board certified in dermatology 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.