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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cuvitru. Based on the available documentation, this patient demonstrates immunoglobulin G (IgG) deficiency, but she has levels of immunoglobulin A (IgA) and immunoglobulin M (IgM) that are within normal limits, which does not meet the criteria for common variable immunodeficiency (CVID). Although she has a history of waning pneumococcal antibody levels over time, she has responded adequately to the combination of Pneumovax and Prevnar with +10/14 serotypes or 71% serotypes with adequate values. Per the American Academy of Allergy, Asthma and Immunology (AAAAI), the records do not support specific antibody deficiency. In the absence of an indication for the requested treatment, Cuvitru 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: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested surgery for treatment of the enrollees un-descended testicle.   Findings:  The physician reviewer found that the cause of cryptorchidism is multifactorial. An un-descended testis can be located anywhere between the abdominal cavity and just outside the anatomic scrotum. This patients medical records state that the testicle was by the external ring but could be linked to the upper scrotum. In the medical literature, Puri and Nixon described normal testicular descent as a testis that remains stationary within the dependent portion of the scrotum. Therefore, cryptorchidism is a developmental defect in which the testis fails to descend completely into the scrotum. A retractile testis withdraws spontaneously out of the scrotum toward the inguinal canal by an active cremasteric reflex but can easily be brought down into a dependent position within the scrotum and remains there after traction has been released. If a testis can be milked down to the bottom of the scrotum, it is probably retractile and does not require therapy, however, there is debate regarding whether retractile testes are a subtle variant of their un-descended counterpart. In cases of ascent, boys previously documented to have normally descended testes are found later in childhood to be cryptorchid. Ascent probably represents an un-descended testis that is almost completely descended. Oftentimes, the testis is located in a superficial inguinal pouch and is diagnosed as un-descended with somatic growth. Therefore, children with retractile testes should be monitored regularly, at least up to puberty, until the testes are no longer retractile and remain intrascrotal. Based on the published literature, the studies report higher than anticipated cumulative orchiopexy rates of 2% to 4%, with the mean age at surgery reported to be 7 years in the majority of series. The most common testicular position was observed to be distal to the external inguinal ring, and in about half the cases the processus vaginalis was patent. Although Puri and Nixon reported that children with retractile testes have normal testicular volume and a normal fertility rate in adulthood, testicular development has been reported to be abnormal in both retractile testes and ascending testes, with histology similar to that of un-descended testes. As this patients records demonstrate that he does not have a normal descended testicle the recommended orchiopexy is medically indicated and necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 5/325 mg one tablet every six hours as needed and physical therapy for treatment of the enrollees neck, shoulder and back pain. Findings:  The physician reviewer found that based on the documentation submitted for review, Percocet 5/325 mg one tablet every six hours as needed has not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with a number of medical problems, including psychiatric behaviors. She has long history of seeking narcotics for pain. Due to the patients chronic non-cancer pain and addictive history, the request for Percocet is not clinically indicated. However, physical therapy as an adjunctive measure for treatment of the patients reports of pain is medically necessary. In patients with pain syndromes, there is a role for physical therapy to help function and mobility to improve quality of life. As such, the request for physical therapy 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for monthly Octagam infusions (HCPCS J1568).The submitted documentation supports the medical necessity of the requested services. The Health Plans denial noted that the patient could be tested to see if she makes enough antibodies using certain vaccines. While this patients IgG 1 level is considered borderline low given her age, the IgG 3 level is considered low. The literature demonstrates that individuals with low IgG 1 and IgG 3 levels can be at risk of recurrent sinopulmonary infections even despite normal antibody production in response to vaccinations. Therefore, it would not be appropriate to judge the patients immunodeficiency status on her response to vaccines. Given the history of recurrent pulmonary infections in the setting of these laboratory values, immunoglobulin replacement therapy is medically indicated. Therefore, monthly Octagam infusions (HCPCS J1568) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested skilled nursing, physical therapy, occupational therapy and speech therapy   for treatment of her left basal ganglia hemorrhage. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this clinical setting.  This patient has had intracranial bleed, with residual deficits.  The submitted therapy notes show gradual continuing progress towards goals.  The current medical literature indicates that recovery post stroke occurs at varied paces, and can continue for many months.  In this patients case, given evidence of continuing benefit, therapy should be continued.  The patient is likely to make more rapid gains with higher intensity services, as opposed to outpatient care.  All told, continued skilled nursing from the date specified forward and continued physical therapy, occupational therapy and speech therapy from the date specified forward was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old man who has prostate cancer with a PSA of 6.3. The patient has a Gleason score of 6 (3+3) on both sides of the prostate in 3/8 needles biopsied. The majority of the remaining biopsies revealed high-grade intraepithelial neoplasia. Based on Partins Tables, the patient has a 75% chance that cancer is limited to the prostate, a 23% chance of capsular involvement, and a 2% chance of seminal vesicle involvement. The patient wishes to undergo robotic-assisted laparoscopic radical prostatectomy. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence reveals the patients cancer is essentially limited to the prostate and seminal vesicle. As such, any local form of therapy will offer him the best chance for cure. As between laparoscopic and standard radical retropubic prostatectomy, there is no widely accepted evidence currently available showing any significant difference between the two in either local control or perioperative morbidity. Though blood loss is less with the laparoscopic procedure, no blood replacement is required in either the laparoscopic or open procedure. The laparoscopic approach has not been demonstrated to be superior to the current standard, which is the open radical prostatectomy. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female has requested sunitinib (Sutent) 25 mg capsule for treatment of her malignant neoplasm of the pons.  Findings:  The physician reviewer found that this young patient was treated with standard options, but her condition has progressed. The National Cancer Institute (NCI) recommends enrollment in an appropriate clinical trial. This was attempted but this patient was not eligible. At this time, the patients oncologist has recommended treatment with Sutent, where he would closely follow an ongoing COG clinical protocol. Despite the rarity of the condition, one phase I trial of Sutent was tested against diverse pediatric solid tumors and eight of the patients evaluated had glioma. Sutent was not tolerated in those patients who had received prior anthracyclines. Overall, there was no efficacy data from this study (DuBois, et al). In a follow-up to this study, Dubois and colleagues showed stable disease in two patients with high grade glioma. The clinical trials do demonstrate Sutent to be safe. All told, use of Sutent in this patients case is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Botox for treatment of the enrollees hyperhidrosis. Findings: The physician reviewer found that the patient has tried and has reportedly failed Drysol, and has had a significant impact as a result of her hyperhidrosis. The condition of hyperhidrosis is known to be socially disabling, and can be very disruptive. Management strategies in the literature include oral medications, topicals such as Drysol, and Botox.  The use of oral medications is not supported by robust evidence.  In addition, side effects such as fatigue or sedation are not uncommon.  On the other hand, Botox is well studied for hyperhidrosis, with an FDA indication for this purpose.  Data supports high effectiveness with low side effects. A recent study of treatment in adolescents notes that when using quality of life measures, health outcomes improved markedly. In sum, Botox is medically necessary in the treatment of the patients medical condition.   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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammaplex intravenous immunoglobulin (IVIG) 45 gm x 3 days every four weeks. Although other interventions such as plasma exchange and intravenous methylprednisolone therapy can be beneficial in patients with transverse myelitis, IVIG is supported as safe and effective for use in this patients clinical setting. Duarte and colleagues reported a reduction in intensity and extension of abnormal T2 signal within one week of treatment, symptomatic improvement in the ability to walk, and magnetic resonance imaging (MRI) findings of disease resolution within three months. After excluding other causes, this patient was diagnosed with systemic lupus erythematosus (SLE)-associated longitudinal extensive transverse myelitis. Treatment has included high-dose steroids without substantial improvement. Treatment with IVIG resulted in symptomatic improvement. For these reasons, the requested Gammaplex IVIG 45 gm x 3 days every four weeks 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 Gammaplex IVIG 45 gm x 3 days every four weeks 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurology and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommend that RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, the patient had been treated in the ER for alcohol related problems three of the five days prior to admission, including at least one admission for life-threatening severe alcohol intoxication. The patients withdrawal symptoms included tremors, anxiety, chest pain, insomnia, sweating, unsteady gait, and psychomotor agitation. His prior rehabilitation services, including IOP and RTC services, were not sufficient as evidenced by yearly relapse. This patient required a safe and stable living environment in order to develop recovery skills. The medical records support an ASAM Level III treatment score, indicating he qualified for a level of care similar to what he received at the facility for the dates of service in question. The medical records support that the severity of the patients illness, including admissions for life-threatening alcohol intoxication and residential treatment, was in accordance with generally accepted standards of medical practice. Accordingly, the residential treatment center (RTC) services were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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

The parent of a 12-year-old female enrollee has requested growth hormone therapy(Genotropin)for treatment of the enrollees short stature. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that this patients hormonal workup was unrevealing. A growth chart has not been provided and thus the patients growth rate is unknown. Additionally, the heights of her parents are not documented in the submitted documentation. Thus, mid-parental height cannot be calculated. The submitted documentation does not include gestational age, birth height, birth weight, a bone age study or adult height estimation. Growth hormone therapy (Genotropin) is not medically indicated for this patient, as the submitted documentation has not demonstrated that the patients meets clinical indications for growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested reimbursement for use of a Dynasplint for the treatment of his contracture. Findings:  Two physician reviewers found that the patient underwent palmer fasciectomy to release the contracture. Dynamic splinting devices such as the Dynasplint can be beneficial following this procedure. The use of the Dynasplint allows for a low-load, prolonged duration stretch to the finger joint and helps improve range of motion. It is an important adjunct to the rehabilitation process for patients such as this patient. The use of the Dynasplint in this setting was likely to have been more successful than hand therapy alone or a standard static splint.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested a referral to a diethylstilbestrol (DES) knowledgeable doctor for the treatment of the enrollee, who is a DES daughter. Findings:  The physician reviewer found that this patient has already been properly evaluated for abnormalities, which has taken into account her history of DES exposure. She has had thorough breast and pelvic examinations, mammography, cervical and vaginal cytology and a screening vaginal and cervical colposcopy.  Her transient minimal pap smear abnormality was managed based on established national criteria, and this was appropriate as noted by the National Cancer Institute.  All of this is well within the realm of routine gynecologic care available within her Health Plan, and there is no medical indication for her to see another provider elsewhere for the same evaluation.  In summary, there is no medical indication for her to be seen by an outside or additional consultant at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested intensive outpatient (IOP) treatment for her behavioral health problems. Findings:  The physician reviewer found that without an ongoing intensive outpatient program, it is highly likely the patient would have relapsed back into depression and anorexia nervosa. The services at issue are considered standard of care by most providers in the psychiatric community.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees back and leg pain.  Findings:  The physician reviewer found that The requested MRI of the lumbar spine is not medically necessary for evaluation of the patients medical condition. In this case, a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs is medically reasonable and appropriate. In addition, the patients medical condition is complicated by use of Forteo which has known side effects including dizziness, tachycardia, muscle cramps, leg cramps, and joint pain. For the reasons provided, the requested diagnostic procedure has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology 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 patient is a 10-month-old male with documented congenital muscular torticollis and lambdoid synostosis. A neurosurgeon recommended treatment with a DOC cranial band. The Health Plan has denied reimbursement for the device on the basis that it was not medically necessary for treatment of the patients condition.Since it is now recommended that infants sleep exclusively on their backs, positional plagiocephaly is becoming more common. Conservative positional treatment is effective in most cases. Use of a cranial band is reserved for treatment of patients with severe problems. Given this patients documented congenital muscular torticollis and lambdoid synostosis and the failure of positional treatment, cranial band therapy was medically reasonable and appropriate and should be continued. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.