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 Spinraza. Spinraza is an antisense oligonucleotide that is designed to increase the expression of the survival motor neuron protein. Spinraza has been approved by the U.S. Food and Drug Administration (FDA) as a disease modifier for patients with SMA. This patients medical records document the presence of residual motor function allowing the patient to engage in some of the activities of daily living. However, the patients muscle weakness has continued to progress. Given the current medical literature, this patient is likely to benefit from Spinraza to reduce disease progression and prolong the patients ability to function.  Given the lack of alternative treatments in this setting, Spinraza is a medically appropriate next step for treatment of the patients condition. All told, the requested Spinraza is medically necessary for treatment of this patients SMA. 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 patient has requested authorization and coverage for Botox injection. The American Headache Society (AHS) recommends preventive treatment when migraine attacks significantly interfere with a patients daily routine despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. OnabotulinumtoxinA (Botox) is U.S. Food and Drug Administration (FDA) approved for chronic migraine. Per the American Academy of Neurology (AAN), Botox is recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. The AAN noted that Botox has been demonstrated to be effective in increasing headache-free days and should be considered to improve health-related quality of life in patients with chronic migraine. The records provided for review support that this patient has a history of chronic migraines, which have not responded to multiple oral abortive and preventative medications. The provider documented that the patients symptoms have persisted despite treatment with Tizanidine, Baclofen, Imitrex, and nortriptyline. Based on the AHS and AAN recommendations, this patient is a candidate for prophylactic treatment with Botox therapy. Given these findings, the requested Botox injection is 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: Urgent Care
Decision: Upheld

A 42-year-old male enrollee has requested reimbursement for surgical services in an emergent or urgent. Findings:  The physician reviewer found that he had a significant injury to his right arm that needed immediate attention in the emergency department. After stabilization, the wound was bleeding only minimally, there was no pain, and there was good vascular supply to the hand distal to the injury. By prudent layperson criteria, the emergency/urgency had resolved. A prudent layperson in this situation would have been sufficiently stable to discuss coordination of his medical care with hospital staff.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral radiofrequency ablation of the perforator veins. This patient is status post bilateral greater saphenous vein and small saphenous vein ablations in September 2020. The patients provider has recommended bilateral radiofrequency ablation of the perforator veins. However, based on the available documentation, the patients perforator veins are not supported as the likely cause of his persistent symptoms. There is an absence of an assessment of arterial perfusion, which is especially important given the patients history of pelvic injury and persistent disabling symptoms despite ablation of all four major superficial veins. Moreover, there is inadequate documentation in the medical records that the patient continues to have function limiting symptoms despite bilateral greater saphenous and small saphenous vein ablations. A duplex examination of the right leg noted that the patients persistent symptoms are mild. The reflux in the perforator veins does not establish an indication for radiofrequency ablation procedures. For these reasons, the requested bilateral radiofrequency ablation of the perforator veins is not medically necessary for 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 board certified in surgery with subspecialty certification in general vascular 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 anesthesia services for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that The American Gastroenterological Association Institute (AGAI) noted that possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse, and patients who are uncooperative or delirious. The AGAI also noted endoscopic procedures that may require an anesthesia specialist include endoscopic retrograde cholangiopancreatography (ERCP), stent placement in the upper gastrointestinal tract, and complex therapeutic procedures. In this case, the patient presented without comorbidities or complex endoscopic procedures that would necessitate the use of a monitored anesthesia care. As such, the anesthesia received was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with receptive and expressive language delays. The records noted that the patient does not have any meaningful words. She waved and clapped appropriately. The provider noted that speech therapy was not recommended due to the patients limited ability to participate in therapy in a one-on-one clinical setting. The patients parent has requested coverage for speech therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested speech therapy is medically necessary for treatment of the patients medical condition. The patient was described as shaking her head for no and using symbolic gestures. She babbled, waved and clapped appropriately. This would suggest that she has the pre-linguistic requisites to benefit from speech therapy. Researchers reported the identification of developmental problems in a childs acquisition of speech, language and/or communication is a core activity in child surveillance. These delays can confer disadvantages in the long-term, adversely affecting language, cognition, academic attainment, behavior and mental health. Patients presenting with significant speech and language delay should be investigated with a comprehensive hearing assessment and be considered for speech and language therapy assessments. Medical evidence supports the requested services in this clinical setting. Therefore, the requested speech therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with a special qualification in child 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

A 41-year-old female enrollee has requested human acellular tissue matrix (AlloDerm) assisted breast reconstruction for the treatment of her breast reconstruction. Findings:  Three physician reviewers found that AlloDerm has been FDA approved as banked human tissue with no specific indication or contraindication. Thus, a physician may use this product in any manner he reasonably desires or needs to use banked human tissue. AlloDerm has been widely reported in the post-mastectomy breast reconstruction population with minimal adverse responses. AlloDerms proponents claim it yields improved aesthetic outcomes in breast reconstruction when compared to existing technologies. AlloDerm is not in limited use, rather, it is becoming widely used. The use of AlloDerm has been proven by numerous studies to be safe and effective within the plastic surgery community (as referenced above). The use of AlloDerm for patients undergoing post mastectomy breast reconstruction is well supported and is likely to result in a better clinical outcome.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Medtronic 670G hybrid closed loop system device. Findings:  Three physician reviewers found that in multiple studies collected in referenced meta-analyses, insulin pumps have been able to demonstrate improved mean blood glucose concentration, glucose variability, hemoglobin A1C and to reduce insulin requirements by 14% over multiple daily injections of insulin in patients capable and motivated to use the pump . It remains the best available option for type 1 diabetes. CGM systems including real-time systems have U.S. Food and Drug Administration (FDA) approval. In addition, the peer-reviewed literature and American Diabetes Association supports the use of long-term CGM devices in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia. The Medtronic MiniMed 670G has the capability of adjusting basal rates to avoid hypoglycemia and suspending insulin delivery to avoid hypoglycemia. All told, the requested Medtronic 670G hybrid closed loop system device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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 number one and two are board certified in pediatrics with sub-specialty certification in pediatric endocrinology and are actively practicing. Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee requested comprehensive inpatient neurocognitive rehabilitation for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that acute brain injury rehabilitation programs have been shown to provide benefit to patients with cognitive dysfunction.  In this case, the patient has documented cognitive dysfunction including problems with comprehension, expression, problem solving and memory.  There is data in the medical literature that demonstrates the utility of cognitive rehabilitation programs in this clinical setting.  All told, the requested comprehensive inpatient neurocognitive rehabilitation is likely to be of greater benefit than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for whole exome sequencing. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee who has a history of mycoplasma pneumonia.  Findings: There is sufficient support in the medical literature for the efficacy of WES in this clinical setting. Based on the patients documentation, he would be a good candidate for WES, given his multi-system disease, with progressive pulmonary disease, immune system abnormalities, complement abnormalities, joint pain, and abdominal symptoms.  These multisystem findings increase the likelihood of an underlying single gene disorder, which can be identified by WES. Researchers identified causative diagnosis in 25 percent of 250 probands studied with WES. This yield is higher than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. A study found similar detection rates. For these reasons stated above, WES is likely to be more effective than the available standard modalities for the evaluation of this patients medical condition.Final Result: Three reviewers determined that whole exome sequencing is likely to be more beneficial than the available standard therapy for evaluation of patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in pediatrics and genetics 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 52-year-old male enrollee has requested robotic laparoscopic partial nephrectomy for treatment of his right renal mass.  Findings:  Three physician reviewers found that the current published peer-reviewed studies have not demonstrated that robotic partial nephrectomy is superior to laparoscopic partial nephrectomy. Comparison of conversion to open rates, ischemia time, recovery of renal function, and operative time have not shown any benefit of robotic partial nephrectomy over laparoscopic partial nephrectomy. Given the lack of clinical data showing superior outcomes with robotic partial nephrectomy over conventional laparoscopic partial nephrectomy, the requested services are not likely to be more beneficial than standard alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intramuscular (IM) amino acids methionine, proline, and cystine; placement in a treatment program for chronic Epstein-Barr virus (EBV) using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy. Per the current evidence-based peer-reviewed medical literature, treatment with intramuscular (IM) amino acids and prolotherapy are not recommended for patients with fibromyalgia, spine pain, Ehlers-Danlos syndrome, or any of the patients listed diagnoses in the medical records. Tzadok and Ablin noted that fibromyalgia is involved with neural oversensitization and decreased conditioned pain modulation (CPM), combined with cognitive dysfunction, memory impairment, and altered information processing. The authors reported that, only three drugs, pregabalin, duloxetine, and milnacipran are currently FDA-approved for fibromyalgia treatment. This patients records do not demonstrate that she has failed standard therapies including pregabalin, duloxetine and milnacipran. Therefore, the requested IM amino acids methionine, proline, and cystine; placement in a treatment program for chronic EBV using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested IM amino acids methionine, proline, and cystine; placement in a treatment program for chronic EBV using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy are not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in allergy and  immunology and rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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

A 65-year-old female enrollee has requested Morphine 15mg, up to 4 times per day for treatment of her chronic pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Authorization and coverage of Morphine 15mg, up to four times a day is not medically necessary. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point appropriate doses of controlled release narcotics, if indicated with close monitoring by a certified pain management specialist, is highly recommended (Fishman). Moreover, high dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Morphine 15mg, up to four times per day is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested gene testing (BRCA1 and BRCA2) for medical evaluation of her history of breast cancer. Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  This patient reports no family history of cancer, and her personal history of breast cancer entails a diagnosis that occurred above the age of 50.  The tumor was unilateral, and not triple-negative. She is not reported to be of Ashkenazi heritage.  Based on the above history, her risk of carrying a deleterious BRCA mutation is not sufficiently high to justify screening.  All told, the requested BRCA1 and BRCA2 testing is not likely to be of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old male with a long history of asthma and allergic rhinitis presumably secondary to multiple inhalants. This is confirmed to some extent by his significantly elevated total IgE. On the other hand, the spirometric study is not particularly remarkable and the graph suggests an incomplete maximal effort.  The patients provider has requested authorization for Xolair.  The Health Plan denied the request based upon a determination that the medication is not medically necessary.Although the FEV1 is 81% of predicted, the FEV-1/FVC is only minimally abnormal. Additionally, a review of pharmacy records suggests only intermittent use of anti-asthmatic medications.  As such, the spirometric values clearly do not fulfill medical necessity criteria for Xolair use.  Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested services on an emergent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with right lower back, hip and leg pain and rated her pain. However, on physical examination it was noted that the patient appeared in no distress and her vital signs were normal with no history of acute injury. Thus, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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.