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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Vyvanse. The records document that this patient has symptoms of impaired processing speed, working memory, and learning. The records document that the patient has difficulty following instructions. Although the diagnosis of attention deficit hyperactivity disorder (ADHD) is not listed in the records, the patient demonstrated improvement in his school performance while treated with Vyvanse, and his symptoms are suggestive of ADHD, which frequently coexists with autism spectrum disorder. Previous treatment with Adderall XR and Concerta were ineffective, and Focalin caused insomnia. In the medical literature, Najib and colleagues describe that Vyvanse is a stimulant agent with low abuse and diversion potential that can be beneficial in the treatment of ADHD in children and adults. Cortese and colleagues conducted a meta-analysis of the available medical literature on the comparative efficacy and tolerability of oral medications for ADHD in children and adults. The authors concluded that Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. This patient underwent a stepwise trial of other stimulant medications, which have either been ineffective or have caused insomnia. Concerta and Adderall XR did not improve his symptoms, while Focalin caused insomnia. Vyvanse was effective in improving the patients school performance and was well tolerated. All told, the requested Vyvanse 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 with 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: Upheld

Physician 1: The patient is a 36-year-old male who has a long-term history of back and neck pain. A discogram showed disc protrusion at L5-S1. The patient was treated with nerve blocks and trigger point injections without sustained pain relief. The patients physician has recommended the patient undergo a nucleoplasty. The Health Plan has denied authorization for the requested procedure indicating the efficacy of nucleoplasty for treatment of the patients condition has not been established in peer-reviewed literature.Nucleoplasty is a treatment for radicular pain and leg pain due to a contained disc protrusion. It is not a treatment designed for low back pain. It has not been tested in this setting in any controlled clinical trials. As such, there is insufficient evidence the requested procedure is likely to result in a superior outcome over standard therapies. Accordingly, 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 36-year-old male with degenerative disc disease. He has requested authorization and coverage for nucleoplasty for treatment of low back pain secondary to disc protrusion at L5-S1. The Health Plan has denied coverage for the requested procedure on the basis it has not been proven efficacious for treatment of low back pain.Nucleoplasty is not the standard of care for treatment of this patients low back pain. There is no Class I data with significant follow-up to support the use of nucleoplasty in this clinical setting. The proposed procedure is not of established efficacy and is not recommended for treatment of the patients medical condition. Therefore, I have determined that the procedure at issue 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 36-year-old male with a long history of discogenic back pain. He has been treated with nerve blocks and trigger point injections without sustained benefit. The patient has consulted a provider who indicates the patient is a candidate for nucleoplasty. The Health Plan has denied coverage for the proposed procedure citing lack of proven efficacy.There are no randomized, controlled trials demonstrating the long-term success of nucleoplasty in the treatment of discogenic back pain. Nucleoplasty is without proven benefit in the treatment of this patients condition. There are no prospective, controlled trials establishing the safety and efficacy of nucleoplasty for this category of patient. 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Pushtronex 420 mg/3.5 mL wearable injector for treatment of the enrollee, who has a history of hyperlipidemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has dyslipidemia and significantly increased coronary risk, but no documented cardiovascular disease. There is a lack of documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  These diagnoses require not only elevated low-density lipoprotein (LDL) levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis, tendon xanthomas), a strong family history of coronary disease, and documented genetic defects related to cholesterol metabolism, according to published criteria. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. The documentation does not support that the patient fits either of these criteria. PCSK9 inhibitors have not been studied in other patient populations, such as in this clinical setting. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, the requested Repatha Pushtronex 420 mg/3.5 mL wearable injector is not medically necessary for the treatment of this patient. Final Review: 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) for integration therapy. The American Psychological Association (APA) recommends offering cognitive behavioral therapy (CBT), cognitive processing therapy, cognitive therapy or prolonged exposure therapy to patients with PTSD. The APA guidelines provide conditional recommendation for EMDR. The International Society for Traumatic Stress Studies (ISTSS) guidelines also include a sequencing of treatment with initial emphasis on safety with skills for emotional regulation and life stabilization. EMDR is not considered treatment for the acute intervention of PTSD symptom exacerbation but is a valid option for the longer-term treatment of this complex disease entity. In this patients clinical setting, cognitive therapies and exposure therapy are more strongly supported than EMDR. The emphasis is to first stabilize the patient in terms of safety and risk as well as emotion regulation prior to initiating any specific trauma-focused psychotherapy. In reviewing this patients history and current presentation, safety and emotion regulation have not yet been established. The patient requires stabilization prior to initiating a trauma-focused therapy, particularly since the trauma-focused therapy can be further destabilizing initially. Given these findings, the requested EMDR services are not medically necessary for 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 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested a wireless capsule endoscopy for an evaluation of her ischemic colitis. Findings:  Two physician reviewers found that chronic abdominal pain is a common complaint that can evade diagnosis even with an extensive work-up. Wireless capsule endoscopy (WCE) is a new method for visualization of the entire small bowel. To date, there are no randomized controlled trials in the peer reviewed medical literature pertaining to WCE for evaluation of abdominal pain. The clinical data suggests that WCE is approved for the evaluation of patients with obscure gastrointestinal (GI) bleeding, iron deficiency anemia with negative colonoscopy and esophagogastroduodenoscopy (EGD). Further, Voderholzer and colleagues comment that WCE may be helpful in evaluating patients with suspected Crohns disease and other small bowel diseases such as tumors, family polyposis syndrome, and arteriovenous malformation. Bardan and colleagues studied 20 patients with chronic abdominal pain and concluded that WCE lacked significant clinical value in the evaluation of patients with obscure chronic abdominal pain. In another study by Tatar and colleagues, WCE was the most effective diagnostic tool in evaluation of patients with anemia (61%) and diarrhea (36%) and least effective in patients with abdominal pain (17%). Based upon this patients history of abdominal pain and ischemic colitis, the use of WCE was not medically indicated as the etiology of her symptoms was most likely due to ischemic colitis.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested Aranesp injections for treatment of his sickle cell anemia.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The anemia of sickle cell disease is very difficult to treat.  Blood transfusions can provide immediate relief and alleviate pain crises, but the patient is placed at high risk of iron overload.  The records noted a history of fatigue and pain crises, and the patient has been treated with iron and blood transfusions.  More recently, the patient has been treated with Aranesp.  In this clinical setting, there are no other standard alternatives available.  There is sufficient support for Aranesp in this patients case.  Therefore, the requested Aranesp injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male has requested Nutropin AQ 20mg/2mL for treatment of his idiopathic short stature.   Findings:  The physician reviewer found that based on review of the available records, although this patients height is more than 2.5 SDs below normal for age and gender, his growth velocity, screening growth factors, and the results of provocative GH testing were all normal. His adult height prediction is not short enough to meet medical necessity criteria for treatment of idiopathic short stature, and his birth weight for gestational age was normal, so he does not qualify for GH treatment on the basis of being born small for gestational age with failure to catch up in growth. According to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. All told, the requested GH therapy is not supported as medically necessary for treatment of this patients medical condition as he does not meet most of these criteria.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee requested magnetic resonance imaging (MRI) of the lumbar spine without contrast (72148), cervical spine (72141), and bilateral shoulder without contrast (73221) for medical evaluation of his bilateral broken clavicle.   Findings:  The physician reviewer found that clinical evaluation did not include a neurological examination or a detailed shoulder exam on either side. Overall, there are no red flags to provide an indication for MRI imaging of the cervical, lumbar spine, or either shoulder. In addition, there is no note in the records of any attempt to treat the patient conservatively with physical therapy before considering any advanced imaging. The requested MRI of the lumbar spine without contrast (72148), cervical spine (72141), and bilateral shoulder without contrast (73221) are not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury. Findings:  The physician reviewer found that with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.  Therefore, the power seat elevation feature is needed in this patients case.  This recommendation is consistent with the current standard of care in the field of rehabilitation medicine.  Customized power mobility equipment to allow independence with transfers is an appropriate practice in rehabilitation.  Because power seat elevation significantly facilitates transfers and promotes independence in this patients case, the requested power seat elevator for her power wheelchair is medically indicated. Final Result: The reviewer determined that the requested equipment 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Humatrope 24 mg cartridge. The U.S. Food and Drug Administration (FDA) approves the use of Humatrope for the treatment of children with growth hormone deficiency. In this case, the records note that the patient had failed two standard growth hormone provocative tests and displayed a growth velocity Z-score below two standard deviations. In this clinical setting, growth hormone therapy is medically indicated until the patient completes puberty. Given that this patient meets generally accepted diagnostic criteria for growth hormone deficiency, the requested medication is medically indicated. Therefore, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 16-year-old female enrollee has requested residential treatment services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found the patient was struggling with identity formation. Complicating this developmental task was the presence of depression, health concerns, and an eating disorder. As such, a conservative admission was appropriate. The medical documentation indicated that the patient received active treatment consistent with current practice guidelines and relevant peer-reviewed literature. The treatment was expected to improve her condition and prevent a more serious illness. The disputed services helped the patient identify a recurrent negative automatic thought of fearing failure, and included the full range of therapies, which shifted focus as discharge approached to facilitate a seamless transition to a less restrictive setting. Considering these variables and clinical presentation, continued residential treatment is safe, appropriate and medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Belbuca (buprenorphine). The providers notes state that the current treatment goal is to treat the patients pain in a more effective manner without drastically escalating the daily morphine equivalents. The provider has recommended continued use of the Belbuca patch. Researchers reported on a meta-analysis and review of 33 studies assessing the safety and efficacy of buprenorphine in the treatment of patients with chronic pain. The authors concluded that buprenorphine is an atypical opioid that demonstrates efficacy similar to full mu-opioid receptor agonists in managing chronic pain while exhibiting a favorable tolerability profile, including the reduced likelihood of abuse potential and respiratory depression. A recent expert consensus guideline on chronic pain management found that buprenorphine should be considered before some opioids in patients with a favorable risk-to-benefit profile on the basis of metabolic factors, abuse potential, and tolerability. Overall, the most recent peer-reviewed medical literature supports the efficacy of buprenorphine for use in patients with chronic pain and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to an improved safety profile, tolerability, and non-inferior analgesic effects. Based on this support, the requested Belbuca (buprenorphine) 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 anesthesiology with subspecialty 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: an enrollee has requested authorization and coverage for intravenous (IV) magnesium via home IV infusion. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Magnesium is primarily absorbed from the gastrointestinal tract, and diarrhea can result in magnesium losses.  Low magnesium level can result in multiple symptoms consistent with this patients presentations, and can also cause cardiac arrhythmias, so treatment of hypomagnesemia is necessary.  The patient has had severe gastrointestinal side effects with oral magnesium. However, the medical literature indicate that intravenous magnesium can result in larger and more rapid increases in magnesium levels than oral magnesium. Additionally, hypomagnesemia and hypermagnesemia present with similar symptoms, so rapid laboratory testing of magnesium level may be needed during infusion to determine the actual magnesium level.  Excess magnesium can be associated with hypotension, drowsiness, muscle weakness, respiratory depression, cardiac arrhythmia, coma, and death.  The cardiac abnormalities are manifold which may include bradycardia, complete heart block, atrial fibrillation, and asystole (cardiac arrest). As such, monitoring and administration in a setting in which emergency treatment can be provided is advisable. Moreover, the prescribing information approved by the U.S. Food and Drug Administration, magnesium overdose is manifested by a sharp drop in blood pressure and respiratory paralysis, and artificial ventilation must be provided until a calcium salt can be injected IV to antagonize the effects of magnesium (Package insert). 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 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.