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

The patient is a 47-year-old female who had a body mass index (BMI) of 34.8 in January 2006 as well as hyperlipidemia, glucose intolerance and a family history of diabetes. She has tried various means to lose weight, but has not been successful in the long term.  Her provider recommended a bariatric surgery consultation and submitted a request for authorization to the Health Plan. Authorization was denied based upon a determination that the service is not medically necessary.The patient is a candidate for bariatric surgical evaluation based on a BMI wavering on or near 35 and hyperlipidemia. There is also real potential for the development of additional co-morbid conditions if her weight is not brought under control.  The Swedish obesity study affirms that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.  Further evaluation of this patient by a specialist in the area of bariatric surgery is medically appropriate at this time. Therefore, I have determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested weekly mental health individual therapy sessions for treatment of her depression.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) practice guidelines for major depressive illness, it is appropriate to consider a change in treatment approach when little to no improvement is noted. The National Alliance on Mental Illness (NAMI) also suggests that if a patient with major depression does not respond to medication management and psychotherapy within a short period of time, the diagnosis of major depression should be questioned. Based on the records reviewed, patients condition has had little to no improvement after what appears to be over eight months of treatment in PHP, IOP, individual counseling and medication management. The provider indicated that the patient had not shown any improvement and recommended ECT. The patient preferred to continue with the individual counseling. The patient was not comfortable with the group counseling in the IOP setting. Further, there are no clear goals stated within the medical records. Therefore, continuation of weekly psychotherapy visits will not benefit this patient, and will not provide improvement in her symptoms. A reevaluation of patients medication regimen in its entirety is appropriate, given this patients complex medical history. All told, continuation of weekly individual counseling sessions is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees 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 (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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  All told, Zepatier is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested testing for the amount of infliximab and antibodies to infliximab for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  While there have been testimonials, there are few well controlled clinical trials to confirm that use of this testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Therefore, testing for the amount of infliximab and antibodies to infliximab was not likely to have been more effective than other methods of evaluating this patient.  Final Result: Two 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:  All three physicians are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing.  All three reviewers are experts in the treatments 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 breast augmentation surgery. The World Professional Association for Transgender Health (WPATH) lists breast augmentation surgery as a medically necessary treatment for gender dysphoria. WPATH notes that surgical procedures such as breast augmentation are often of great practical significance in the patients daily life and are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the gender dysphoria. In this case, given that the patient has a diagnosis of gender dysphoria, and as the provider has recommended breast augmentation surgery, the requested services are medically indicated. In this patients case, breast augmentation surgery is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, breast augmentation surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for substance abuse. The American Society of Addiction Medicine (ASAM) criteria, a set of objective guidelines used by providers to assist with treatment planning, advocates for service intensity provided in the least intensive, but safe treatment setting. The ASAM guidelines advise that length of service should be determined by the patients progress with his or her treatment plan as determined by the treating providers. Per the documentation, this patient has a long history of substance use. In addition, the patients providers noted that she is unable to control her impulses and remains at high risk for relapse. Thus, treatment at the IOP level of care is consistent with the current medical literature, ASAM criteria, and the documented clinical history. Accordingly, the IOP level of care services were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

A 52-year-old male enrollee has requested a powered mobility scooter for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed by a physical therapist and it was noted that he could ambulate household distances within the home without an assistive device and could also use a walker with seat as needed.  The current medical evidence does not support the requested equipment in this clinical setting.  The records do not establish that the patient would be bed or chair confined without a power mobility device.  The documentation indicates that the patients in-home mobility needs would be met with a walker with a seat.  Moreover, physical activity is generally appropriate for general musculoskeletal health and for chronic pain syndromes.  All told, the requested powered mobility scooter is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old female enrollee has requested intensive outpatient programming (IOP) treatment for the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not and are not medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, this patients diagnoses include autism spectrum disorder and reactive attachment disorder.  These are chronic conditions that will continue to require intervention on a long-term basis. Participation in an IOP program was initiated following problems with physical boundaries and excessive aggression. The patient was responding to verbal prompts to recognize physical boundaries, was engaged in interactive tasks and showed improved ability to follow a structured schedule, follow directions and respect physical boundaries. According to the documentation submitted for review, the patients school has a behavior therapist and is working with her teachers to implement a positive behavior support plan in the classroom. While the patient does continue to experience symptoms, subsequently she had progressed to the point that she could continue to work on behavioral skills outside the structure of an IOP program. Thus, based upon the documentation provided, the medical necessity of continued IOP treatment onward has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee requested anterior lumbar fusion surgery for medical treatment of his low back and bilateral leg pain. Findings:  The physician reviewer found that the patients MRI with contrast documented postoperative changes at L5-S1 with minimal enhancing scar tissue surrounding the S1 nerve roots left greater than right. A diagnosis of failed spinal surgery and complex regional pain syndrome is therefore appropriate. However, anterior fusion as a treatment method is not supported by evidence of instability or recurrent intervertebral disc herniation.  A more conservative approach has been recommended including continuing physical, movement and cognitive therapies. For these reasons, the requested anterior lumbar fusion surgery is not medically necessary for treatment of this patients back pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fasenra 30 mg auto injector pen. The medical records provided for review document that this patient complains of dyspnea, asthma, and chest congestion. The provider charted that the patient has been diagnosed with systemic eosinophilia. Based on current medical literature, it is medically appropriate to treat this patient with a type 2 targeted therapy, given his eosinophilia in the setting of severe asthma. However, there is a lack of data to support the treatment with Fasenra over other type 2 targeted medications. Mepolizumab has been demonstrated to be safe and effective for use in this clinical setting. Bel and colleagues noted that, In patients requiring daily oral glucocorticoid therapy to maintain asthma control, mepolizumab had a significant glucocorticoid-sparing effect, reduced exacerbations, and improved control of asthma symptoms. Pavord and colleagues concluded that, Mepolizumab is an effective and well-tolerated treatment that reduces the risk of asthma exacerbations in patients with severe eosinophilic asthma. Overall, there is a lack of data supporting that Fasenra is superior to mepolizumab. This patients records do not document that the patient has failed an adequate trial with mepolizumab. Therefore, the requested Fasenra 30 mg auto injector pen is not medically necessary for 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 internal medicine with subspecialty certification in allergy and immunology 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 transoral incisionless fundoplication (TIF) with EsophyX device. The efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials. However, the conclusions are contradictory. A large randomized trial included 60 patients and found no improvement in esophageal acid exposure compared with baseline at 12 months. The study concluded that no long-term objective reflux control was achieved. Guidelines do not recommend endoscopic procedures for patients with complicated gastroesophageal reflux disease, which the guidelines define as dysphagia or Barretts esophagus, both of which the patient has, and report that the long-term follow-up data for TIF is limited.  These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. For these reasons, transoral incisionless fundoplication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewer 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: 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: Experimental/Investigational
Decision: Upheld

The mother of a 16-year-old female enrollee has requested for a pneumatic compression cooling therapy unit for treatment of the enrollees postoperative shoulder condition. Findings:  Three physician reviewers found that there is no indication in the medical records that the pneumatic compression cold therapy unit was required for postoperative healing of this patients right shoulder.  Additionally, data confirming the efficacy of pneumatic compression cold therapy over traditional treatment is lacking.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested cervical spinal fusion for treatment of his neck pain. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  The medical records noted a disc protrusion at C6-7 which appears to impact the exiting nerve root.  However, the medical records do not document that the patient has had progressive neurologic deficit or another indication for urgent surgical treatment prior to the exhaustion of conservative care.  The current medical literature supports the exhaustion of conservative measures prior to surgery in this setting.  In this patients case, there is an absence of a sufficient degree of conservative care, such as physical therapy.  Therefore, the requested cervical spinal fusion is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested outpatient comprehensive rehabilitation day program (physical therapy, occupational therapy, speech therapy and cognitive behavioral therapy) for treatment of the enrollee, who has a history of basal ganglia intraparenchymal hemorrhage. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of basal ganglia hemorrhage.  Following acute care and rehabilitation, he continued to have impairments, including weakness and difficulty with cognitive skills.  Doig and colleagues performed a study comparing the efficacy of outpatient rehabilitation in day hospital and home settings.  The authors concluded that differences in gains made by patients treated in day hospital versus home settings were not statistically significant, although the authors noted higher levels of patient satisfaction with treatment in the home setting.  Although there is evidence supporting the need for continued therapies, the medical literature does not demonstrate that day treatment as an outpatient has a better probability of good outcomes as compared to a home-based treatment program.  All told, the requested outpatient comprehensive rehabilitation day program (physical therapy, occupational therapy, speech therapy and cognitive behavioral therapy) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 25-year-old woman who has requested reimbursement for a bunionectomy that was performed in April 2003. The Health Plan has denied this request indicating that the procedure at issue was not medically necessary. The submitted information does not document conservative treatment prior to surgery. The Health Plans denial should be upheld. Review of the submitted records does not demonstrate that there was an adequate course of conservative therapy prior to bunion surgery. Additionally, there was no pre-operative x-ray of the bunion deformity to support the procedure. Furthermore, the operative report reflects a bunion with soft tissue release while the billing information indicates an osteotomy was performed. Thus, the submitted records do not demonstrate that the procedure at issue was medically indicated.Based upon the information set forth above, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz oral tablet. Sandborn and colleagues found that patients with moderately to severely active ulcerative colitis treated with tofacitinib were more likely to have clinical response and remission than those receiving a placebo. Rogler notes that Janus kinase (JAK) inhibitors constitute a promising new class of drugs for the treatment of Crohns disease. In this case, the patient has severe fistulizing and stricturing Crohns disease complicated by perianal abscess. As he has failed all major classes of therapy and guideline-recommended biologic alternatives for the treatment of Crohns disease, strict adherence to guidelines would result in uncontrolled disease with potentially severe clinical consequences. In this clinical setting, treatment with Xeljanz may help this patient avoid complications, including fistula, disease flare, stricture, hospitalization, and need for surgery, and is medically indicated. Therefore, Xeljanz oral tablet 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 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.