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

The parent of a 16-year-old male enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature secondary to GH deficiency based on GH stimulation test. Findings:  The physician reviewer found that based on review of the available records, on initiation of GH therapy, the patient met criteria for GH deficiency, as his height was more than 2 standard deviations below normal and results of provocative GH testing showed a peak GH response less than 10 ng/mL. Currently, the patient is in the midst of his pubertal growth spurt. Despite the fact that the patient has already attained a height that is within the normal range for a fully grown adult, it would be inappropriate to withdraw GH therapy in this GH deficient adolescent while he is in the midst of his pubertal growth spurt. As GH is important for other factors besides growth, such as deposition of muscle mass, bone density, and cardiovascular health, GH is medically necessary until the patients growth velocity slows to less than 2 cm per year and/or epiphyses are closed on bone age X-ray, at which point his status should be reassessed in the context of adult standards for determining medical necessity of GH therapy. Continuation of GH therapy is therefore medically necessary for treatment of this patients medical condition for one year with reevaluation at that time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a five-year-old female with an articulation difficulty involving F, L, and S sounds. She was evaluated by a speech and language therapist who also diagnosed her with an auditory processing disorder. The therapist recommended speech therapy once a week to improve language and phonemes structure. At issue is whether the recommended therapy is medically necessary for the patients condition.The National Institute on Deafness and Other Communication Disorders (NIDCD) describes auditory processing disorders in basic terms. The NIDCD reports little research has been performed on these diagnoses, especially in the realm of treatment. To date, there is insufficient evidence speech therapy has a beneficial role in treating the patients disorder. Given the lack of literature supporting the diagnosis and its treatment with speech therapy, medical necessity for the requested therapy has not been established. Therefore, 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 ceftriaxone (Rocephin) 2 Grams IV daily for 4 weeks.The submitted documentation does not support that the requested medication is medically necessary. In this case, the patient does not meet U.S. Centers for Disease Control and Prevention (CDC) criteria for having Lyme disease, because she does not have a positive screening test nor does she have positive IgM and IgG western blots. Moreover, there are no symptoms described that are consistent with central nervous system Lyme disease, and the patients cerebrospinal fluid findings were normal. Accordingly, the patient does not meet diagnostic criteria for Lyme disease. Solitary positive IgM testing (i.e., without a positive IgG) is usually a false positive result. Therefore, the requested medication, ceftriaxone (Rocephin) 2 Grams IV daily for 4 weeks, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 infectious disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL Pen injectors. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis when symptoms are not adequately controlled with topical therapies. Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. This patients records document moderate-to-severe atopic dermatitis with almost 35% BSA involvement. In addition, Dupixent has high quality clinical trial evidence demonstrating its safety and efficacy in the treatment of patients with atopic dermatitis (Siegels, et al.). Systemic cyclosporine is not recommended for long-term use due to toxicities and is an immunosuppressive that has been associated with increased infection risk. Additionally, immunosuppressives such as prednisone, methotrexate, mycophenolate, azathioprine, and cyclosporine can reduce the response to vaccinations. This patients provider noted that the patient has failed topical steroids with triamcinolone, systemic steroids, and hydroxyzine. Considering the patients 35% BSA involvement, topical calcineurin inhibitor application is not recommended. For these reasons, the requested Dupixent 300 mg/2 mL Pen injectors are 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 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:  An enrollee has requested authorization and coverage for Orencia.Findings: According to the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, the addition of biologic disease-modifying antirheumatic drugs (DMARDs) (i.e., Orencia) or targeted synthetic DMARDs (i.e., Rinvoq or Xeljanz) is recommended when escalating therapy to optimize rheumatoid arthritis disease control. The guideline also indicates that there is no recommendation for a targeted synthetic DMARD over a biologic DMARD. Either drug class is an acceptable next line agent when escalating therapy to optimize disease control. In this case, the patient has tried and failed conservative therapy with minocycline and hydroxychloroquine. Therefore, Orencia is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the 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 sub-specialty certification in rheumatology 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 28-year-old male enrollee has requested substance abuse subacute residential treatment provided from time frame specified for treatment of his chemical dependence, anxiety disorder and bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation showed no evidence of acute withdrawal, metabolic instability or psychiatric instability (no suicidal ideation, homicidal ideation, psychosis) that would have placed the patient at increased risk or which would have necessitated a 24-hour supervised setting. Most behavioral therapies are applicable across a range of treatment settings, modalities and to a wide variety of populations, i.e. disease model, behavioral or motivational approaches can be applied in inpatient, outpatient or residential settings (Frances, et al). The submitted documentation identified treatment goals as establish affective coping skills to manage mood, strengthen internal motivation to prevent relapse. In summary, both of these goals could have been accomplished in an outpatient dual diagnosis treatment setting. As such, the medical necessity of the treatment provided has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablet for 12 weeks for treatment of the enrollees chronic hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for radiofrequency ablation procedure (CPT 36475) on the left leg and radiofrequency ablation procedure (CPT 36475) on the right leg. The submitted documentation supports the medical necessity of the services at issue. In this case, the records documented that the patient was having significant symptoms attributable to the varicose veins. The records documented evidence of severe reflux in the veins that were treated, and that the treatments performed were limited to the veins with documented reflux. Given that the services at issue were appropriate for the documented symptoms, the services at issue were medically indicated. Therefore, radiofrequency ablation procedure (CPT 36475) on the left leg and radiofrequency ablation procedure (CPT 36475) on the right leg were medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the ReWalk personal exoskeleton system for treatment of his medical condition.  Findings:  Three physician reviewers found that the ReWalk personal exoskeleton system is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Lajeunesse and colleagues conducted a systematic review of lower limb exoskeletons, including ReWalk, for spinal cord injury. The authors concluded The applicability and effectiveness of lower limb exoskeletons as assistive devices in the community have not been demonstrated. More research is needed on walking performance with these exoskeletons compared to other mobility devices and other training contexts in the community. The authors further stated that The level of scientific evidence is low. Other studies are needed to provide more information about performance over the longer term when walking with an exoskeleton, compared to wheelchair mobility, the users usual locomotion, the use of different exoskeletons or the training context in which the exoskeleton is used. There is some medical literature that supports the device as safe in a supervised setting with some health benefits. However, there is a lack of medical literature showing the application of ReWalk outside of supervised settings. In addition, it is unknown if the requested device can be safely and practically be incorporated into an individuals daily routine in their home and community environments. The medical literature does not address the management of a fall when an individual is inside the device away from clinicians familiar with its function. Additionally, the health benefits conferred by standing and aerobic exercise do not require the ReWalk device. All told, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested device 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: All three reviewers are board certified in physical medicine and rehabilitation and are 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

An enrollee has requested authorization and coverage for Otezla 30 mg tablets. ESTEEM 1 is the first phase III study confirming the efficacy of apremilast in psoriasis. Apremilast demonstrated significant improvements in mean percentage change in psoriasis area and severity index (PASI) scores and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. There is sufficient support for the requested medication in this clinical setting. Therefore, Otezla 30 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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

The parent of an eight-year-old female enrollee has requested speech therapy services for treatment of the enrollees verbal apraxia. Findings:  The physician reviewer found that the patient has received speech therapy and has made measurable and significant progress. Notes from this therapy indicate a need for close monitoring, evaluation and modification every 12 months. Considering the severity of this patients speech and language deficits, speech therapy sessions have been, and continue to be, medically necessary and essential. The patients quality of life, education, growth and development will depend on her participation in a speech therapy program. Periodic assessments and reevaluations should be conducted, and will dictate the type and frequency of future therapy.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested prostate magnetic resonance imaging (MRI), three Tesla high resolution for medical treatment of his prostate cancer.  Findings:  The physician reviewer found that this patients most recent PSA was normal at 1.8.  If the patient has a rising PSA, the medical literature shows a distinct advantage of MRI of the prostate using a 3 Tesla system over the conventional 1.5 Tesla units.  However, a recent PSA was not provided in this patients case.  All told, the requested prostate MRI, three Tesla high resolution is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested spinal fusion surgery for treatment of her low back pain with radiation down the right leg. Findings:  The physician reviewer found that in the medical literature, Parker and colleagues caution against fusion surgery as a first-line surgical intervention due to the significant follow-up surgical interventions that generally result from spinal fusion. Additionally, Deyo and colleagues noted that long-term benefit of spinal fusion surgery in the absence of instability is not supported due to long-term complications that oftentimes require further surgical intervention. All told, this patient has progressive neurological deficits that would benefit from surgical intervention. However, the clinical documentation submitted for review does not support the requested fusion surgery at L5-S1 as a medically necessary first-line surgical intervention for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Opdivo (nivolumab) for treatment of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting.  Opdivo is not supported for the treatment of metastatic colon cancer by major drug compendia.  The current medical literature does not demonstrate the superior efficacy of the requested medication in this patients case.  Based on the submitted documentation, Opdivo is not likely to be of greater benefit than other treatment options.  Final Result: 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines state that in some patients with soft tissue sarcomas, PET imaging may be useful for prognostication and treatment planning. This was the case for this patient, as her primary tumor was only partially resected. PET imaging may be beneficial for evaluating the activity and size of the primary tumor. This modality has been shown to be more sensitive than conventional imaging in the diagnosis or detection of metastatic disease, often in unexpected locations.  Positron emission tomography/computed tomography (PET/CT) scans allow for such evaluation with one total body scan, whereas conventional imaging would have required multiple scans of various organ systems to achieve the same level of information. Therefore, PET scan was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology 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: Medical Necessity
Decision: Upheld

A male enrollee requested 16 home health visits of skilled nursing for treatment of his medical condition.  Findings:  The physician reviewer found that  according to the documentation submitted for review, the patient was provided with six home health visits, however, there is no mention in the documentation supporting the need for additional home health services. The patient indicates in his application that he needs more nursing help, although there is no medical justification provided for review. Hence, the request for 16 home health visits is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 62-year-old female enrollee has requested continued skilled nursing facility care for the treatment of her multiple medical conditions. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that the patient has severe anoxic encephalopathy. The records provided for review reveal that she has been unable to progress with daily skilled therapy. Further, she does not require daily therapy to maintain her current functional status. Tube feeding was ceased and she did not have daily wound care. The patient was administered IV vancomycin during dialysis but subsequently has not required the medication on more than a weekly basis. All told, the submitted evidence reveals no indication for continued skilled nursing services or skilled rehabilitation therapy. The patients needs as of the last authorized date of service have been custodial in nature.