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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) level of care with daily sessions with a therapist, psychologist and psychiatrist. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on the available documentation, this patient presents with some risk of harm (score 2) The patient has demonstrated challenges in performing activities of daily living (ADLs), but he has been able to adequately perform ADLs (score 2). The patient has been able to share in individual and group therapy. The patient has no reported medical, substance use, or developmental issues (score 1). The patients recovery environment is described as stressful and tense (score 3). The provider noted that the patients family has a history of unresolved conflicts leading to an inability to solve family problems. The patient has few other relationships for support. The patients recovery environment lacks support (score 3) as the patient has parents and a home to return to, but his parents have not actively reached out for family sessions. The patients treatment has resulted in moderate response (score 3) due to the patients improvement with medications, and participation in treatment with fewer suicidal statements. The provider noted that the patient was reluctant to take medication and participate in therapy (score 3), but eventually complied. The patients parents have not been actively involved with family therapy with the patient (score 3). This CALOCUS scoring gives the patient a score of 20, which is consistent with partial hospitalization program (PHP) level of care. Therefore, the requested RTC level of care with daily sessions with a therapist, psychologist and psychiatrist are not supported as 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 with subspecialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with chronic plaque psoriasis affecting 5% of his body surface area (BSA). He has tried and failed therapy with topical steroids and tanning booths. The medical records indicate the patient has a history of diverticulitis. However, there is no data provided to indicate that the patients diverticulitis is active or ongoing. While immunosuppressive agents are not indicated during active infections, the records provided at this time do not give enough details to determine whether the patient has ongoing infections requiring continuous treatments. As there is a lack of evidence for contraindication of usage of the preferred formulary agents, the request for coverage of Otezla is not supported as medically necessary for treatment of this patients plaque psoriasis. 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 dermatology 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 Ozempic. The records provided for review document that this patient has a history of type 1 diabetes complicated by end stage renal disease, hypothyroidism, and dyslipidemia. The patients provider reports that the patient has responded well to a combination of insulin and Ozempic in the past. The provider has recommended continued treatment with Ozempic, which is a member of a class of medications called glucagon like peptide 1 (GLP-1) receptor agonists, which have demonstrated effectiveness for hemoglobin A1C reduction with additional weight reduction and no intrinsic risk of hypoglycemic episodes. GLP-1 receptor agonists are recommended as the preferred first-line injectable glucose-lowering therapy for patients with type 2 diabetes, even before insulin treatment (Nauck, et al.). Recent data supports the use of a combined therapeutic regimen of insulin and GLP-1 receptor agonists for treating patients with type 1 diabetes mellitus. Combination therapy with GLP-1 and insulin can help achieve an ideal treatment effect on glycemic control, weight loss, and bolus insulin dose in patients with type 1 diabetes mellitus (Wang, et al.). Given this support, the requested Ozempic 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Jakafi. Jakafi is approved for the treatment of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis. Jakafi is the only JAK2 inhibitor approved for use in myelofibrosis and generally reserved for the treatment of symptomatic myeloproliferative disorder with our without splenomegaly. While treatment with Jakafi significantly improves both symptoms and the quality of life of patients with myeloproliferative disorder, it has not been demonstrated to reduce the risk of leukemic transformation, which can be achieved through the use of stem cell transplant. This patient is asymptomatic, lacks splenomegaly, and does not meet these criteria. All told, Jakafi is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Jakafi is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients poor outcome is a consequence of the initial operative technique utilized in this case rather than patient non-compliance. The operative report indicates that a shorter Roux limb was created resulting in less malabsorption than the more effective 150 cm common channel technique. The study by Hess and colleagues confirms this finding and further states that the occurrence of the need for re-operation in patients with short limb LRYGBP is becoming more frequent, especially in the super obese patient. The records also appear to indicate that the patient did attempt diet, exercise and medications after her pregnancy with poor results. Additionally, it has been difficult for the patient to exercise given that she has also developed plantar fasciitis which cannot be treated with non-steroidal anti-inflammatory drugs (NSAIDS) due to the increased risk of ulcer formation or gastritis in patients who are status post LRYGBP. While re-operation is associated with significant risk, there is also a very high probability that without revisional surgery the patient will develop severe obesity-related co-morbidities with highly negative impact on her health, especially in light of her high BMI. The results of the Torgerson study clearly show that life expectancy in patients with a similar BMI is greatly reduced. Several studies support re-operation as a legitimate approach to correct a failed LYRGBP in selected patients. All told, surgical revision to duodenal switch is the best treatment option for this patient as it is likely to result in significant weight loss and thereby prevent the development of serious co-morbidities; improve her electrolytes, vitamin deficiencies and anemia, allow the patient to initiate NSAID therapy to relieve the symptomatology associated with her plantar fasciitis and thus start being able to exercise; and relieve her dumping syndrome, if present.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for an esophagogastroduodenoscopy (EGD). The enrollee has hypertension and hypercholesterolemia with complaint of abdominal pain. She stopped taking levothyroxine due to fear that it was causing her pain.  The gastroenterology record indicates a rounded abdomen.  The treatment plan included referral to a rheumatologist, laboratory work, a computed tomography (CT) scan of the abdomen with contrast dye, and an esophagogastroduodenoscopy (EGD) without biopsy.  The enrollee reports abdominal pain.  However, the record does not indicate the pain is upper abdominal.  The enrollee does not have alarm symptoms, such as anemia, weight loss, GERD that is unresponsive to therapy, or a lesion on the CT scan.  The enrollee does not meet guidelines for the performance of this test.  Since there is insufficient evidence in the record of persistent upper abdominal pain, the requested EGD is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Cinqair infusion for treatment of the enrollees severe persistent asthma. Findings:  The physician reviewer found that the documentation provided fails to demonstrate the medical necessity of the requested medication in this clinical setting. The submitted progress notes from the ordering provider do not list any medications. The progress notes list no chief complaints, no physical examination and no past medical history.  The progress note indicated that the patient presented with cough, wheeze, shortness of breath and sneezing while on Advair 500, montelukast, Spiriva, theophylline and prednisone.  However, there are no other progress notes to support that the patient continued to experience uncontrolled flare up while on the medication regimen.  There is a lack of documentation across a longer span of time to show that the patient has tried and failed the formulary medications, or that she has experienced uncontrolled flare up while being compliant with these medications.  As such, Cinqair infusion is not medically necessary for treatment of this patients medical condition.   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 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 enrollee is requesting authorization and coverage for the drug, mupirocin powder 100%. The enrollee has a history of asthma, chronic sinusitis, allergic rhinitis, and atypical aspirin-exacerbated respiratory disease. She has been treated with medications and endoscopic sinus surgeries. The enrollees otolaryngologist prescribed mupirocin powder, 100%, and reports this is the only medication suited to treat her symptoms. A randomized, controlled study of the use of nasal lavage, with and without mupirocin, in 20 subjects showed the subjects in the mupirocin nasal lavage group demonstrated lower nasal endoscopy scores post-operatively, and a statistically significant, larger difference in nasal endoscopy scores at one month, compared to one week. The mupirocin group also showed better Sino-Nasal Outcome Test scores at one month, compared to the group without mupirocin. The use of mupirocin powder rinse is reasonable approach for this enrollee with a very complicated sinus disease.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested testosterone pellet implants for the treatment of her endometriosis. Findings:  Three physician reviewers found that the scientific literature suggests that the use of testosterone may be of benefit for treating endometriosis and enhancing libido in postmenopausal women. However, at the present time, it can only be considered investigational as the specific use of testosterone pellets is debatable and not supported in the medical literature. The use of transdermal testosterone affords an alternative delivery system that has been the subject of greater study, and as such, has better outcome data than testosterone pellet implantation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested removal of all facial lesions, moles and spots for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There is no reason to remove benign skin growths which have been evaluated by a dermatologist, out of concern of future malignancy.  The patient is not considered to be high risk for skin malignancy, as the records do not document a history of organ transplant, immunosuppressive medications, or long-term history of photochemotherapy.  The patients family history of squamous cell carcinoma does not confer enough risk to remove these lesions for prophylactic therapy.  All told, the requested treatment to remove all facial lesions, moles and spots 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 board certified in dermatology 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 54-year-old female enrollee has requested for Nexium and Lipitor for treatment of her hypercholesterolemia and gastroesophageal reflux disease. Findings:  The physician reviewer found that proton pumps inhibitors (PPIs) continue to be the backbone of therapy for acid suppression and continue to be the standard of therapy for the treatment of GERD. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. It is medically appropriate to require that the patient have a trial of formulary alternatives such as Omeprazole, Aciphex, or nonformulary alternative, Prevacid. It is also medically reasonable to base approval for Nexium upon failure to respond to adequate trials of these agents.Statins are widely prescribed for the treatment of dyslipidemia. Statins increase low density lipoprotein (LDL)-receptor expression on the hepatocyte surface, increase uptake of LDL and decrease circulating LDL. Statins also decrease triglycerides and modestly increase high density lipoprotein (HDL) levels. While all statins have the same mechanism of action, they differ in terms of chemistry, pharmacokinetics, potency and approved indications. Rosuvastatin (Crestor) and atorvastatin (Lipitor) are the most potent statins with respect to lowering LDL, followed by simvastatin (Zocor) and pravastatin (Pravachol). It is medically appropriate to require that the patient have a trial of formulary statins (Vytorin and Zocor). Approval for Lipitor may reasonably be made contingent upon the failure of these formulary agents.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the air and associated ground ambulance transportation services. She suffered a significant, life-altering, hemorrhagic stroke, which left her with severe dysphagia, right-sided weakness and left-sided hemi-neglect. She was non-ambulatory and required intense physical therapy and occupational therapy. At the time of her discharge from inpatient rehabilitation she remained non-ambulatory. Her team of caregivers, in consultation with family, determined that it was not medically appropriate for her to be discharged for ongoing therapy in her home, though she also did not require continued inpatient rehabilitation services. Therefore, it was determined that the most medically appropriate way to handle her ongoing need was to have her transferred for continued, pre-arranged rehabilitation and related professional services by a home-based healthcare agency. Ground transport was contraindicated given the great time and distance involved was an estimated 2,467 miles and 36 hours for transportation. The only medically appropriate way for the patient to get to the most appropriate next phase of her ongoing care was transport by medically-configured, fixed-wing aircraft given her non-ambulatory status and need for monitoring en route. Although the transportation was not an emergency and the transportation was not to a hospital, the treatment plan was to transfer to the most medically appropriate place where the patient would be receiving pre-arranged ongoing professional services in a familiar environment and with her daughter that had received training specifically for this purpose. After review of the available medical records and documents, as well as review of applicable literature, the services were medically necessary and appropriate 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Findings: The records document that this patient presents with a history of obesity, obstructive sleep apnea (OSA), and prediabetes. The patient has attempted treatment with exercise and diet, with some improvement in hemoglobin A1C level. The patients provider has recommended treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Currently, there are multiple pharmacologic therapies are available to assist patients with weight management. Wegovy is a member of a class of medications known as glucagon like peptide 1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk in obese patients. Multiple studies have demonstrated the ability Wegovy to promote weight loss, via reduced appetite and energy intake, as well as delayed gastric emptying. Given these findings, the requested Wegovy 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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.