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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Stelara 390 mg re-induction infusion and (2) Stelara 90 mg injections every four weeks Re-induction doses of biologic therapy in Crohns  disease have been reported as successful to regain response. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, researchers observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The 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 severe Crohns  disease diagnosed before age 30, a history of stricture and fistula, and recent need for laparoscopic ileocolectomy. He has failed multiple biologic and conventional alternatives. His symptoms are consistent with active Crohns disease despite Stelara 90 mg every eight weeks. A Stelara level of at least 4.5 ug/mL is associated with effective disease control, however in this case, the patients Stelara level was 1.4 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, (1) Stelara 390 mg re-induction infusion and (2) Stelara 90 mg injections every four weeks 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 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

A 41-year-old male enrollee has requested Oseltamivir to reduce his risk for contracting H1N1 virus and passing it to his pregnant wife and/or newborn child. Findings:  The physician reviewer found that this patients request is not consistent with recommendations for the prophylactic use of oseltamavir. The Centers for Disease Control and Prevention (CDC) indicates that antiviral agents are discouraged for prevention of illness in healthy children or adults based on potential exposure in community, school or other settings. The document also notes limited safety data for these drugs in healthy adults. Even if used for treatment purposes in the event the patient develops influenza-like symptoms, prevention of transmission is not absolute as patients with H1N1 influenza are contagious for one day prior to onset of clinical symptoms. Thus, the proposed use of a prophylactic antiviral to prevent H1N1 influenza in the patients high-risk spouse and/or newborn child is not recommended by CDC guidelines, nor has it been studied to determine its efficacy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that In the medical literature, Reichow and colleagues reported that ABA is an effective treatment modality for children with autism spectrum disorder. Linstead and colleagues showed that higher intensity ABA consisting of 35-40 hours per week leads to better outcomes in learning and language primarily, but also in behaviors like elopement or tantrum. Given the research showing that higher intensity and longer duration provide better outcomes, 40 hours per week of direct applied behavioral analysis (ABA) provided was and is medically necessary for treatment of this patients autism spectrum disorder. 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 pediatrics 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 Repatha injection. Findings:  The physician reviewer found that this patient presents with increased coronary risk, including hyperlipidemia, but no documentation of clinical coronary disease or heterozygous familial hyperlipidemia.  Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied only in patients with heterozygous familial hypercholesterolemia or in patients with documented clinical atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. This patient does not fit either of those categories. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated low-density lipoprotein levels that significantly exceed threshold amount, but also a combination of physical examination findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. There is no documentation to support clinical coronary disease, such as angina, myocardial infarction or prior coronary revascularization. Studies that have evaluated Repatha do not include patients without familial hyperlipidemia or clinical cardiovascular disease.  PCSK9 inhibitors have not been studied in other patients for primary prevention and are not recommended in this patient group according to current guidelines. Thus, the requested Repatha injection 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 cardiovascular disease 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 weekly individual therapy with a psychologist for treatment of his depression and adjustment disorder.   The physician reviewer found that this patients underdeveloped ego-strength is consistent with distorted beliefs about his self, his personal world and his future, which is synonymous with the classic cognitive triad. As such, the patient can be expected to do well with cognitive based therapy. As noted by Sadock and colleagues, there is ample evidence supporting the role of cognitive behavioral therapy (CBT) in patients with depressive disorders. Considering family history, the cyclical maladaptive patterns of behavior and the chronicity and nature of the symptom complex, a typical course of CBT consisting of 12 weekly sessions of individual CBT provided, followed by a diagnostic re-evaluation to assess progress and ongoing treatment needs, is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

The parent of a two-year-old male has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorder. Rather, at issue is the notion that plasticity in the developing brain still exists despite underlying neurological disease and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested excess skin and subcutaneous skin removal for the treatment of her excess skin condition. Findings:  The physician reviewer found that the medical records do not establish medical necessity for the proposed skin removal. The body contouring procedure has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patients history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in her skin folds. Nor is there photographic evidence documenting cellulitis, ulcerations or rashes. The submitted treatment records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either failed to respond to topical therapy or despite initial response, have recurred and caused significant functional impairment. The patients condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. The records do not provide any objective medical documentation of infections or evidence that the patient has ever seen a physician for assistance with the medical management of infections. Surgical intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets by mouth daily for eight weeks. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets by mouth daily for eight weeks are 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for left knee arthroscopy (with partial medial and lateral meniscectomy, chondroplasty patella and excision of plica). This patients knee pain was evaluated with magnetic resonance imaging (MRI), which is an accurate modality for evaluation of meniscal tears. The negative MRI with regard to the medial and lateral menisci indicates absence of a significant tear. The fraying of the meniscal edge may represent a minor degenerative change but does not generally constitute a significant meniscal tear and thus did not require an arthroscopic partial meniscectomy. When discovered at the time of arthroscopy, shaving is an option. The synovial plica may become symptomatic due to inflammation or trauma and cause knee pain, requiring arthroscopic partial synovectomy. The patients records document that conservative measures were exhausted, and surgery was indicated. On review of the operative report, the arthroscopy of the left knee with partial synovectomy with excision of the synovial plica and chondroplasty were indicated and consistent with medical literature recommendations. However, the partial medial and lateral meniscectomies were not medically necessary based upon the operative report description of normal meniscus with small fraying in the posterior horn of the medial meniscus and some fraying of the root of the lateral meniscus. Given these findings, a portion of the left knee arthroscopy services (chondroplasty patella and excision of plica) was medically necessary for this patient, while the partial medial and lateral meniscectomies were not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia service provided during a colonoscopy performed for evaluation of the enrollees risk for colon cancer. Findings: The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for iontophoresis. Current medical literature on iontophoresis for musculoskeletal abnormalities focuses on calcific tendinosis, which this patient does not have. Ling and Lui describe iontophoresis as a procedure which transmits localized dexamethasone via an electrical current deep to the skin into the inflamed tendon. There is a lack of data in current medical literature supporting the efficacy of iontophoresis for the treatment of musculoskeletal abnormalities, including tenosynovitis, and a lack of significantly large, double-blind, placebo-controlled studies comparing iontophoresis treatment to sham treatment with respect to tenosynovitis. In this case, the patient has insertional posterior tibial tenosynovitis. While the records note that the patient has tried and failed numerous conservative treatments, given that the records do not document trial and failure of cast immobilization, controlled ankle motion (CAM) boot immobilization, or a lace-up ankle brace that may allow for pain reduction, the requested equipment is not medically indicated. Therefore, iontophoresis is 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 licensed D.P.M., board certified in podiatry, 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

Use of Xolair to treat this patients moderate persistent asthma and recurrent infection is not medically necessary since there is inadequate medical chart documentation that the patient was treated with oral steroids more than once in the past year or that he required a visit to the emergency room, or hospitalization, for the management of asthma. The patient demonstrated a positive blood test allergen sensitivity to aeroallergen, and presented with asthma symptoms that appeared to persist despite daily inhaled corticosteroid with Advair, which is a long-acting beta-agonist. He also has demonstrated symptoms that required the use of almost daily Xopenex rescue inhaler. The patient demonstrated a total IgE of. However, spirometry report from medical chart note demonstrated normal function without evidence of airway obstruction and fractional exhaled nitric oxide (FeNO) level was in the normal range. Given lack of documentation of emergency department visits, hospitalizations, use of oral steroids more than once in the past year, in the setting of normal spirometry and normal FeNO levels, there is no indication that patient is in need of add-on therapy with Xolair. 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 allergy and immunology with subspecialty certification in pediatrics 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 Suboxone for treatment of his behavioral health condition.  Findings:  The physician reviewer found that buprenorphine is approved by the U.S. Food and Drug Administration (FDA) for the treatment of opioid dependence.  The patient was prescribed a buprenorphine combination medication that was medically necessary and consistent with accepted medical practice. The dispute central to this case is that the Health Plans non-preferred preparation of the clinically indicated medication was prescribed (film as opposed to sublingual tablet).  There was no evidence in the medical record to suggest that the Health Plans preferred equivalent medication, would have been diverted, poorly tolerated, inefficacious or inadequate at the time.  Thus, although the pharmacologic intervention was indicated, the particular medication was not medically necessary. Final Result: The reviewer determined that the medication at issue was 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 microvascular decompression brain surgery. Several of this patients complaints are consistent with a diagnosis of trigeminal neuralgia since his pain is described as unilateral, generally sharp, electrical, and brief, with triggers such as touching the face. The patient has been treated with carbamazepine, which is considered first-line medical therapy for the treatment of trigeminal neuralgia. When medical management fails to adequately control a patients pain due to trigeminal neuralgia, surgical options include percutaneous rhizotomy, microvascular decompression, or stereotactic radiosurgery. Microvascular decompression has been demonstrated to have the best long-term success in actually addressing the cause of trigeminal neuralgia. Given this support, the requested microvascular decompression brain surgery is medically necessary for treatment of this patients medical condition.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 neurological 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.