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

The patient is a 17-year-old male with previously diagnosed bipolar disorder and conduct disorder, with background history of polysubstance abuse. The patient was admitted to a residential treatment center in May 2003 where he has continued in treatment until this time. A request has been made for continued residential treatment services. The Health Plan authorized treatment until 2/18/04, with intention to shift the patients treatment to an outpatient basis. Chart notes from 2/6/04, indicate the patient though struggling with his anger was stable for the most part with no major ups and downs. He was often noted to attend group therapy but to appear somewhat bored, maintaining a distanced but not outwardly contentious stance. His formal psychiatric evaluation of 2/12/04, notes the patient as doing well with stable mood and no behavioral issues presented. It was also noted the patient refused Depakote. At this point in treatment, Prozac had been discontinued for a month without problems and it was thought that the patient might not actually have had bipolar disorder. As such, Depakote was formally discontinued and the patient was scheduled to be seen in another four weeks or so as needed. The patients next formal psychiatric evaluation of 3/18/04, also noted the patients mood was stable with no symptoms, he was sleeping well with good focus/concentration, and he appeared pleasant/euthymic on exam. Throughout, the patient was not suicidal or nearly as contentious as he had initially presented.The Health Plans denial should be upheld. As set forth above, the submitted records do not demonstrate that continued residential treatment is medically necessary. Many of the serious components of the patients initial clinical presentation, such as fighting, drug use, stalking, and anger, had abated significantly by 2/18/04. In fact, based upon the provided chart notes, they actually extinguished by this point. While there is never a guarantee against relapse, the patient had sufficiently improved to the point that residential treatment was no longer medically indicated as of 2/18/04. By this date there had been sufficient time to transition the patient home and to outpatient treatment. Thus, it was medically reasonable and appropriate to discontinue residential treatment at that point in time. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested bilateral breast MRI for evaluation of her dense breast tissue. Findings:  Two physician reviewers found that per the American Cancer Society guidelines, annual screening MRI is indicated for patients with a lifetime risk for breast cancer of 20 to 25%.  The American Society of Breast Surgeons recommends breast MRI for patients with suspected or proven deleterious mutations of BRCA1 or BRCA2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of developing breast cancer of 18.7%.  There is no personal or family history of BRCA mutation. The patient does not have a history of radiation to the chest wall.  Therefore, in this patients case, the requested bilateral breast MRI is not likely to be more effective than other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested growth hormone Serostim for treatment of his HIV related lipodystrophy.  Findings:  Two physician reviewers found that there are two randomized, controlled trials for the use of Serostim for (HARS). The results of these are included in the FDA approved package insert for Serostim and show significant improvement in visceral adipose tissue in patients treated with Serostim. Of import, visceral adipose accumulation has been linked to dyslipidemia and increased risk of heart disease. The studies caution that some patients had significant adverse events with Serostim including elevated blood glucose levels, but overall, many patients had improved symptoms and sense of well being. Grunfeld and colleagues randomized trial concluded that Serostim can be effective in patients with HARS, and there are no other available treatments. For these reasons, the authors concluded that it is reasonable to approve a trial of Serostim for patients with careful monitoring for adverse events as it is likely to be more effective than other treatments. Another drug (recombinant hGH releasing factor) Tesemorelin is currently being considered by the FDA for approval however, to date there is no currently accepted or effective treatment for this condition. Therefore, Serostim is likely to be the most beneficial for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Genomind Brain Science Genetic Testing for evaluation of his medical condition. Findings:  Two physician reviewers found that studies have shown that clinically useful predictors are scarce for antidepressant therapy, and the results are inconsistent.  They have shown that there is only marginal clinical association between enzyme system variants and medication metabolism, efficacy, and tolerability in the treatment of psychiatric illnesses.  There is a lack of large randomized trials supporting the use of genetic testing in this clinical setting.  The existing studies have also indicated that there was no significant correlation between either genotypes or antidepressant serum concentration and response to antidepressant treatment.  The current evidence does not support the use of genotyping when choosing an antidepressant.  Even less is understood about its utility in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the provider towards choosing a medication regimen.  Thus, Genomind Brain Science Genetic Testing was not likely to have been of greater benefit 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 reviewers are board certified in psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Forteo. Khosla and Hofbauer state, Osteoporosis is an enormous and growing public health problem. Once considered an inevitable consequence of ageing, it is now eminently preventable and treatable.  While anti-resorptive drugs, especially bisphosphonates, are considered standard therapy, Li and colleagues report that pro-formative anabolic drugs, such as Forteo, have attracted wide attention in recent years. The authors further note that randomized controlled trials show a higher efficacy with the use of teriparatide (brand name Forteo) in the treatment of osteoporosis than bisphosphonates such as risedronate. Laura and colleagues report that anabolic therapy is associated with a higher fracture risk reduction than oral bisphosphonates. Therefore, Forteo 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee requested hyperthermia treatment (CPT 77600) for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available options. Hyperthermia is generally used to treat cancers which are progressive or recurrent despite conventional therapy. In this case, the patient has localized prostate cancer which can be treated with several well-established treatments such as surgery and radiation. Moreover, there is a lack of support in the medical literature for the use of hyperthermia for the treatment of prostate cancer. Thus, in the absence of support in the published clinical data, the services at issue were not likely to be more beneficial than any available standard treatment for this clinical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with articular gout. Laboratory results revealed a uric acid level of 9.5 mg/dl. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient has tried and failed treatment with allopurinol, indomethacin, and colchicine. The patient has requested authorization and coverage for brand name Uloric. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether brand name Uloric is medically necessary for the treatment of the patients medical condition. Researchers reported, Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or oral colchicine are appropriate first line options for treatment of acute gout, and certain combinations can be employed for severe or refractory attacks. Per the authors, Low dose NSAID therapy is an appropriate choice for first-line gout attack prophylaxis, unless there is lack of tolerance or medical contraindication. Authors reported, Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option. Steroids are among the most effective anti-inflammatory medications available and have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects. In this case, there was no documentation of the presence of acute or even chronic gouty arthritis on examination or radiographs despite the patients history of increased uric acid. There was also no documentation that the patient has failed to respond to a full dose of allopurinol. Finally, the patient has not tried and failed generic Uloric, and there is no history of intolerance or contraindication to generic Uloric. The patient does not appear to have renal insufficiency. The medical evidence does not support the requested medication in this clinical setting. Therefore, brand name Uloric 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 internal medicine with sub-specialty certification in rheumatology 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 frovatriptan succinate 2.5 mg tablet as needed. Researchers note that migraine is a common neurovascular disorder, and that current guidelines recommend triptans, such as frovatriptan, as first-line treatment for moderate-to-severe migraine attacks. The choice of serotonin agonist may depend on the patients response to different triptans, taking into consideration different pharmacologic properties and delivery routes. In this case, given that the patient has tried and failed sumatriptan and Migranal, and has responded well to frovatriptan, the requested medication is medically indicated. Therefore, frovatriptan succinate 2.5 mg tablet as needed 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 neurology with sub-specialty certification in neuromuscular medicine 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 enrollee is requesting authorization and coverage for Simponi Aria infusions. The patient is seropositive rheumatoid arthritis with an elevated C-reactive protein, and episodic flares of joint pain in the wrists and knees. She is on methotrexate. The patient was on Remicade (infliximab) infusions and experienced hives. The provider is recommending the use of golimumab (Simponi Aria) intravenous infusions as an alternative to Remicade in order to bypass concerns about allergic reactions (hives or urticarial). The provider notes that this patient is needle phobic (has a fear of self-injecting), has chronic wrist pain with dexterity issues making it difficult to self-inject, and is at risk of power blackouts making storage of subcutaneous medications, such as Humira and Enbrel unsafe. As noted by Singh and colleagues, there is no significant difference in potential benefit from the three anti-tumor necrosis factor agents that are used for rheumatoid arthritis (Humira, Enbrel and Remicade), versus the anti-tumor necrosis factor agent being requested by the provider (Simponi Aria). Simponi Aria is an intravenous medication, as well as subcutaneous, and Humira and Enbrel are subcutaneous. The patient has already been on Remicade in the past with a possible reaction. The remaining options for this patient include subcutaneous Humira, Enbrel and Simponi or intravenous Simponi. Given the patients combination of wrist problems, needle phobia and unreliable storage (power blackouts), subcutaneous injections are not reasonable. Therefore, intravenous Simponi Aria is medically necessary for this patient.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for applied behavioral analysis (ABA) services four (4) hours per month of assessment & treatment, four (4) hours per month supervision by BCBA, and ten (10) hours per week of direct 1:1 ABA services by paraprofessional.  The enrollee has a diagnosis of autism. He has currently been in treatment for his autism for five years, with previous applied behavioral analysis (ABA) at a different provider, for a total of fourteen years. The enrollee had been receiving ten hours per week, which has been gradually reduced over time. Therapy goals include communication, self-advocacy, and safety skills. Progress has been slow due to the limited hours. The enrollees mother is involved in all sessions and implements recommendations. He had been displaying higher levels of improvement when receiving 7.5-10 hours per week, as he was meeting 50% of his goals. At five hours per week, he was meeting 30% of his goals. There are no goals addressing vocational skills. The enrollee has a severe prompt dependency, which has been shaped gradually over time. Case notes indicate for ABA therapy to be effective for this enrollee, he requires consistency and repetition in order to learn and effectively meet goals that have been prescribed for supporting his independence. The enrollee requires a systematic generalization of skills across environments, stimuli, instructions and people (including parents). A study indicated that a diagnosis of autism is made when DSM-V symptoms are present and other disorders have been adequately ruled out.  The literature describes applied behavior analysis (ABA) therapy as a behavioral intervention used to treat autism spectrum disorder in which the enrollee's progress is tracked and measured.  This therapy emphasizes communication, play, academics, social, work, community, and self-care. ABA therapy is widely accepted among healthcare professionals and is widely used because it encourages positive behavior and has demonstrated benefits for enrollees with autism.  ABA therapy programs are commonly recommended for 25-40 hours per week, with family support to encourage skill utilization outside of the program. Case notes indicate the enrollee has been displaying higher levels of acquisition when receiving 7.5-10 hours/week; whereas, at 5 hours/week, he was only meeting 30% of his goals. This supports the need for continued intensive therapy for this enrollee with autism. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child & 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested excision of excessive skin and subcutaneous tissue (CPT 15830 and 15847) (abdominal wall panniculectomy) for treatment of her abdominal wall panniculitis. Findings:  The physician reviewer found that the reviewed materials lack documentation of the severity of the panniculitis and non-surgical treatments employed for panniculitis or response to such treatments. The request is for panniculectomy or removal of infraumbilical skin (CPT 15830) and abdominoplasty, or placement of incisions around the belly button and in the lower abdomen to shift supraumbilical skin caudally with removal of the excess at the bottom and creation of a new umbilical opening in this downwardly shifted skin (CPT 15847). The medical necessity of CPT 15847 has not been established, since there are no skin conditions such as rashes or complaints related to the upper abdominal skin fold. Additionally, the reviewed documentation does not justify the medically necessity of CPT 15830.  Documentation including actual prescriptions for topical medications for panniculitis and office visit notes over time listing medications employed to treat panniculitis and the responses to such treatment were not provided.  Based upon the submitted documentations, the pannus is a normal variant and is not large enough to be considered an abnormal structure of the body.  All told, the requested excision of excessive skin and subcutaneous tissue (CPT 15830 and 15847) (abdominal wall panniculectomy) is not medically indicated for the treatment of this patient and is not reconstructive in nature.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) (Gamunex-C or Gammagard) 25-gram infusion every month. Epilepsy and seizure related disorders are due to a wide variety of symptoms including antibody-mediated etiologies. Various antibodies have been identified which target key components to neuronal stability. The presence of these antibodies mitigate seizure threshold and are established causes of epilepsy. Due to their autoimmune nature, therapeutic approaches differ from the standard antiepileptic regimen approach of other epilepsy disorders. Frequently such patients require immunomodulatory therapy to address the underlying etiology in addition to standard antiepileptic medications. This patient has evidence of voltage gated potassium channel antibodies, which are known in the epilepsy disease process. In addition to topiramate, the patient has tried and failed treatment with steroids. IVIG is an accepted therapy for patients with antibody-mediated epilepsy and is the next logical step for this patient, who is no longer responding to steroids. For these reasons, the requested IVIG (Gamunex-C or Gammagard) 25-gram infusion every month is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested IVIG (Gamunex-C or Gammagard) 25-gram infusion every month is 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 medication is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

 A 59-year-old male enrollee requested the neuromuscular electrical stimulating ergometer (RT300 functional electrical stimulation (FES) cycle rehabilitation system) for medical treatment of his spinal cord injury. Findings:  Two physician reviewers found that the equipment at issue was not likely to be more effective for this patient than other available treatment options. The patient has T4 paraplegia.  At the T4 level, the patient is expected to be independent at a wheelchair level and should be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. Based on the information provided, the requested RT300 functional electrical stimulation cycle rehabilitation system is not clinically indicated as the patient at the T4 level should be able to achieve health benefits without the use of the requested equipment.