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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that stimulant medication is the gold standard pharmacologic intervention for ADHD. Concerta is a methylphenidate-based product approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD. Concerta is a central nervous system psychostimulant that has been shown to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. In this case, the patient was previously treated with Concerta, and this represents the most critical factor in the determination process of this particular case. This patient has a proven track record of tolerability and efficacy with Concerta. Additionally, upon continuing care for his ADHD, Concerta was prescribed by his treating provider at a safe, appropriate and conservative dose. Given that the patient has performed well with Concerta, the requested medication has been established as medically necessary for treatment of the patients ADHD. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Orthovisc injections in both knees.An exhaustive review of the 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 as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. 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, there is a history of benefit from bilateral knee injections of Euflexxa in the past. Additionally, other conservative treatments, including physical therapy and corticosteroid injections, have been exhausted. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested Orthovisc injections in both knees are medically necessary for the 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing performed for evaluation of the enrollees malignant melanoma.Findings:  Three physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Final Result: The reviewers determined that the testing at issue was 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 physician reviewers are board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the Medtronic 670G insulin pump. Findings:  Three physician reviewers found there is sufficient support for the requested device in this patients case. Per the medical evidence, the requested Medtronic 670G insulin pump is likely to reduce fluctuations in glycemia. This patient has difficulty communicating episodes of hypoglycemia given his age. This device has been used successfully in children. In this clinical setting, the Medtronic 670G insulin pump will allow the patient to experience less glycemic variability and reduced hemoglobin A1c levels. In sum, the requested Medtronic 670G insulin pump is likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested device is 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: Physician reviewers 1 and 3 are board certified in pediatrics and are actively practicing. Physician reviewers 2 is board certified in pediatrics and pediatric endocrinology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement and authorization and coverage for continued Skilled Nursing Facility (SNF) services.In this case, the patient sustained bilateral hip/femur fractures at the subtrochanteric level, for which she underwent surgical repair. The patient had been improving with therapies, and she was mobilizing household distances with a walker at the contact guard assist level. Records reflect that the patient had otherwise plateaued with respect to her self-care skills, at the moderate assist level for lower body self-care. She did not have any ongoing skilled nursing or medical needs requiring ongoing Skilled Nursing Facility (SNF) level of care. Accordingly, Skilled Nursing Facility (SNF) services provided during the period under review were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: An enrollee has requested authorization and coverage for continued skilled nursing facility level of care from 11/05/16 forward.  Findings:  The physician reviewer found that this patient has sustained a cerebral insult due to neoplastic disease.  He had deficits in cognition and overall functioning, which are not unexpected in this setting.  However, he has responded to treatment that has included intravenous steroids, surgical tumor resection, relative rest, and inpatient rehabilitation efforts.  As of 11/05/16, he was at the supervision level for self-care and basic household level mobility.  He had not yet started brain radiation.  Further care, including rehabilitation interventions, could have been provided in the community/outpatient setting, with caregiver supervision in the residential setting for safety.  He did not have documented treatment needs, such as multiple or frequent intravenous antibiotics, new complex wounds, or other skilled nursing needs, that required ongoing inpatient hospital level care. 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 physical medicine and rehabilitation 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 nine-year-old female enrollee has requested Humatrope for treatment of idiopathic short stature.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that this patient has severely retarded growth. However, the hand x-ray suggests abnormal bone structures and the possibility of achondroplasia. This diagnosis should be explored with a skeletal survey. If confirmed, growth hormone may be appropriate, in which case the request for Humatrope should be reconsidered. However, based upon the information presented at this time, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for Botox injections and prospective authorization and coverage for Botox injections. The US Food and Drug Administration (FDA) approved Botox for headache prophylaxis in patients with adult chronic migraine with headaches on 15 or more days per month, each lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. Botox has not been shown to work for the treatment of episodic migraine headaches that occur 14 days or fewer per month, or for other forms of headache. The available medical records provided for review document failure of at least two medications for prophylaxis of migraine. The records also report the patient is having chronic headaches, migraine type, and does specifically delineate and quantify the frequency of the headaches in terms of days per month on an ongoing basis demonstrating at least headaches lasting four or more hours on 15 days or more per month for at least three months. Moreover, there is documentation that Botox has been effective in reducing the patients headache frequency and severity with positive functional benefit. For these reasons, Botox injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Botox injections were not and are not 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 and 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the peer-reviewed literature demonstrates positivism for TMS, as researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama, et al). In addition, TMS is approved by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient has major depressive disorder and she is symptomatic from her affective illness. Her response to traditionally accepted therapeutic interventions has been suboptimal. The patient is self-advocating for TMS therapy and a consultation with a TMS provider to evaluate the appropriateness of the treatment modality is clinically indicated prior to starting treatment. If, an evaluation results in a recommendation for TMS therapy, then a course of TMS would be considered medically necessary. However, in the absence of a recommendation by a TMS provider, the requested services are not medically indicated at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 63-year-old female enrollee has requested authorization and coverage for an office consultation and follow up visit with a bariatric surgeon for evaluation of the enrollee who has a history of grade II endometrial cancer and obesity. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Late complications of Roux-en-Y gastric bypass can include dumping syndrome, anastomotic stricture, intussusception, gallstone disease, pain, fistula, ulcer, weight regain, and nutritional deficiencies including B vitamins, iron, calcium, copper, vitamin D, selenium, zinc, and vitamin A. The epigastric abdominal pain that required evaluation in the emergency department in July 2017 may have been caused by a number of these complications. These complications are best evaluated by a bariatric surgeon, who is trained to recognize common and uncommon postsurgical complications.  Therefore, the office consultation and follow up visit with a bariatric surgeon are supported as medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immune globulin (IVIG). This patient presents with a history of immunodeficiency due to hypo-immunoglobulinemia. Her disease course has included encephalitis and frequent infections. The provider reported that treatment with IVIG has stabilized the patients condition. While the patient was not being treated with IVIG, she experience an acute worsening of her condition. Common variable immune deficiency (CVID) is a group of heterogeneous primary immunodeficiencies with impaired immunoglobulin production. CVID is characterized by recurrent and/or severe infections, autoimmunity, malignancy, and allergic disorders (Nguyen, et al.). The potential complications of CVID include bacterial meningitis and viral meningoencephalitis, encephalomyelitis, and peripheral neuropathies (Chavoshzadeh, et al.). The medical literature has demonstrated that treatment with IVIG is safe and effective for patients with CVID. One study reported evidence of subjective improvement in quality of life as well as objective improvement in the frequency and severity of infections (Ameratunga, et al.). Given these findings, the requested Gamunex-C IVIG infusions are medically necessary for 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 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 parent of a 10-year-old male enrollee has requested biofeedback/neurofeedback therapy for treatment of the enrollees medical condition. Findings:  Three physician reviewers found the requested services are not likely to be more effective for this patient than any other available options. There is a lack of evidence-based research in the medical literature to support the requested treatment. A review of current studies of neurofeedback in ASD did not find support for its use. The study by Holtmann and colleagues reviewed the effectiveness of neurofeedback in the treatment of ASD and stated that outcomes did not show true improvement in core ASD symptoms. Kouijzer and colleagues studied 38 ASD patients randomly allocated to EEG biofeedback. The authors did not find significant reduction in symptoms of ASD and also found no nonspecific effects of EEG-biofeedback were demonstrated. Additionally, the patients seizure disorder is controlled with medication. Based on the medical literature cited above and the medical records submitted for review, the requested services are not likely to be more beneficial for treatment of the patients autism than standard treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 27-year-old male with back pain dating to January 2005. A request has been made for a two-level artificial disc replacement. The Health Plan has denied this request on the basis that artificial disc replacement remains experimental.Artificial disc replacement remains an unproven procedure at this time. There are no long-term prospective studies to support a two-level disc replacement. The patient is young in age and his pain started less than a year ago. There is no record of a trial of conservative measures. A two-level disc replacement is drastic step without documented long-term benefit. Furthermore, the risks of the procedure are unknown. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 27-year-old male with degenerative disc disease. He has had a positive discogram at L4-5 and L5-S1. His provider is recommending two-level artificial disc replacement at these levels. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. There is no evidence supporting the safety and efficacy of a two-level disc replacement. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 27-year-old man who has degenerative disc disease at L4-5 and L5-S1. His physician has recommended multi-level artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy particularly when a multi-level procedure is involved. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.