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 dextroamphetamine (generic Adderall) 30 mg twice/day.Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral condition that affects most patients throughout their lives and is associated with occupational and functional impairment, psychiatric comorbidity, and substance abuse. Treatment and diagnosis often starts in childhood and is treated by pediatricians, and then continues on to adulthood and is treated by primary care physicians at that time. Due to challenges in access, as well as a shortage in mental health professionals, many people seek treatment of their psychiatric disorders through their primary care physician. A patient may often choose to be treated by his or her primary care physician for several factors including reduced stigma and increased comfort. This practice is the most cost effective way to manage mild to moderate psychiatric disorders, including ADHD. For this reason, treatment of psychiatric disorders in a primary care setting, known as Integrated Behavioral Health, has been a growing trend in primary care settings. Psychiatric organizations have made statements that assert that primary care clinicians should develop competence in ADHD diagnosis and treatment for several of the above reasons. To expect that a patient receive a diagnosis of ADHD from a mental health professional is unrealistic and unreasonable as well as inconsistent with the current standard of care. In this case, the patient has a diagnosis of ADHD from two mental health providers in the past 10 years. She is currently diagnosed with ADHD by her primary care physician, who is an associate professor of medicine at a highly respected academic medical center. Records reflect that the patient has been stable on this medication for over 10 years, and discontinuation of the medication would pose a risk of decompensation. Under these circumstances, the requested dextroamphetamine (generic Adderall) 30 mg twice/day is 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing (81210, 81275, 81301, 81350, 81401, 81404, 81479, 88291, 88313, 88323, 88368, and 88381) for evaluation of her adenocarcinoma of the sigmoid metastatic to the liver. Two physician reviewers found that relying on guidelines issued by the National Comprehensive Cancer Network (NCCN), in newly diagnosed metastatic colon cancer, testing for BRAF, KRAS, and NRAS genetic mutations was indicated in this patients case. Further, because the patient is younger than age 70 with a diagnosis of colon cancer, she was an appropriate candidate for screening for Lynch syndrome. This is achieved with performance of an assay for microsatellite instability (MSI). Thus, testing for BRAF (81210), KRAS (81275), MSI (81301), and NRAS (81404) were clinically indicated. Based on the foregoing discussion, CPT codes 81210, 81275, 81301 and 81404 were likely to have been more beneficial in evaluating this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  Credentials/Qualifications: One reviewer is board certified in clinical biochemical genetics and is actively practicing.  Two 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Flovent HFA 220 mcg for treatment of his eosinophilic esophagitis. The physician reviewer found that according to Goldin and Chan eosinophilic esophagitis (EoE) is an increasingly diagnosed, immune-mediated disease characterized by inflammation of the esophagus. Adults typically present with dysphagia and a history of food impaction. The authors further state that Effective treatment of EoE requires a multidisciplinary approach with gastroenterologists, pathologists, allergists, and nutritionists. Treatments include elimination and elemental diets, topical glucocorticoids (fluticasone and budesonide), and endoscopic dilation. In addition, the van Rhijn and colleagues state Fluticasone propionate treatment decreases eosinophilic inflammation and improves the esophageal mucosal barrier integrity in adult EoE patients. Improvement of the mucosal barrier integrity correlates with normalization of expression of desmoglein-1 and filaggrin marker genes. Based on the peer-reviewed literature and clinical documentation submitted for review, the requested medication is medically necessary for treatment of the patients EoE.  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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an eight week intensive outpatient program services (IOP) for treatment of the enrollees behavioral health conditionFindings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In the documents provided for review, there was a lack of evidence of interdisciplinary treatment planning. There was no mention of the patients level of craving, skills developed, steps worked on, identification of triggers, or relapse prevention.  There was no interdisciplinary treatment plan with goals, description of how further treatment would help the patient improve beyond what she had already achieved in IOP, or if she had even developed skills to manage her symptoms or make changes. Her issues of depression and anxiety, reported on admission, were not addressed.  It is unknown if she had developed, or was in the process of developing, sources of outside support. The patient had no suicidal or homicidal ideation.  She attended and participated in groups. There is a lack of evidence that she requires intensive evaluation and treatment at IOP level of care. The patient may be treated at a lower level of care on an outpatient with concurrent community support, such as a 12 step program. Final Result: The reviewer determined that 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing services for treatment of the enrollee, who has a history of altered mental status. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the patient did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time. He did not require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. During the timeframe in dispute, the patient did not have any parental medications, complex wound care or nutrition given via a feeding tube. Per the records, his function had plateaued by the period of care under review and he did not require any further inpatient skilled rehabilitation services. The current medical evidence does not support the services at issue in this clinical setting. Therefore, skilled nursing services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 Norco 10-325 mg for treatment of the enrollees chronic lower extremity pain. Findings:  The physician reviewer found that Norco is medically necessary for treatment of the patients medical condition. In this case, the patient has an opioid agreement that is very specific in terms of modifying the treatment plan. The opioid agreement specifies that the treating provider will evaluate how well the opioid medication is working. However, the records submitted for review lack documentation showing pain assessments or assessments of the patients function. A pain assessment should include the current level of pain, the lowest and highest reported levels of pain over the period since the last assessment, the average level of pain, the intensity of pain after taking the opioid medication, how long it takes for pain relief to occur, and how long the pain relief lasts. The treating provider would be expected to measure function using any of the readily available tools for measurement. In terms of the planned weaning, a slow taper is recommended and the longer the patient has taken opioids, the more difficult they are to taper. A suggested taper is 10% every two to four weeks. When tapering, patients should be monitored to ensure that pain and function do not worsen as worsening pain and function would support the medical necessity of ongoing opioid therapy. In this case, the patient has been taking Norco on a long-term basis and is opioid dependent. The result of a repeat urine drug screening was positive for Norco and cannabis. The provider recommended slow weaning planned at 60 tablets with a plan to decrease further to 10 tablets the next month and then discontinue the medication. The quantity prescribed represents a 1/3 decrease which is not appropriate for weaning and a further decrease of more than 80% is planned for the next month. If tapered too quickly, worsening pain and function could occur due to withdrawal and the patient has significant comorbid medical conditions that would place him at risk for an adverse outcome if the withdrawal symptoms were severe. For these reasons, Norco 10-325 mg is medically necessary for the treatment of the patients medical condition at this time.  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 physical medicine and rehabilitation 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

The parent of a 4-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism and developmental delays.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested occupational therapy. This patient presents with autism and intellectually disability. The school districts evaluation was able to utilize a Vineland Motor Scale to determine that the patient was deficient in both gross and fine motor skills. A child with such severe fine motor deficiency would benefit from interventional OT. Chase-Smith and Arbesman compiled a meta-analysis of the medical literature, documenting the value of OT in the autistic children population. In addition, Myers and Johnson noted that OT is of significant value when the child transitions into a school setting. Finally, the article by Pfeiffer and colleagues compiled an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the unwanted mannerisms associated with autism. All told, the requested occupational therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sacroiliac joint fusion for treatment of her sacroiliac joint pain.  Three physician reviewers found that SI joint fusion is not the standard of care for the treatment of degenerative back pain and SI joint disorders. In addition, the medical records submitted for review do not demonstrate that this patient has had SI joint trauma, tumor or infection. Fusion surgery for degenerative SI joint conditions has not been established in the medical literature and more long-term outcomes research is needed to establish the safety and efficacy of the procedure. For the reasons provided, the requested services are not likely to be more beneficial for treatment of the patients medical condition than conservative measures. Final Result: Three 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:  All three reviewers are board certified in orthopedic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyosted 75 mg/0.5 mL injection. This patient has a reported history of low testosterone levels with symptoms of fatigue and erectile dysfunction. The provider noted that the patient underwent penile injections for erectile dysfunction, likely due to corporovenous occlusive disease. According to the Endocrine Society guidelines, hypogonadal patients with low testosterone levels and symptoms can be treated with a variety of testosterone preparations including gels, pellets, and injectable therapies. The goal of treatment is to normalize a patients testosterone level. Most symptoms of fatigue, overall wellbeing and sexual dysfunction should improve with normalization of the levels. This patients testosterone levels were noted to be within normal limits with testosterone replacement through pellets and gels, attaining levels as high as 814 ng/dL. Despite this improvement, he has continued to complain of fatigue and persistent erectile dysfunction. The patient reported improvement in his symptoms with Xyosted. However, the records fail to demonstrate that the patient has been treated with and failed standard testosterone preparations to support an indication for Xyosted. Therefore, the requested Xyosted 75 mg/0.5 mL injection is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine 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 30-year-old female enrollee has requested a biopsy or excision of a brain tumor for treatment of her meningioma. Findings:  The physician reviewer found that per the submitted documentation, the patients physicians do not support the requested biopsy or excision.  This patient is manifesting many somatic symptoms with no objective findings.  Small calcifications of the falx are benign.  Additionally, small calcified meningiomas usually do not enlarge quickly and may be watched.  As suggested by the Health Plan, monitoring with follow-up MRI is standard of care.  In this patients case, the requested biopsy or excision is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee requested mental health residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the medical records indicate that the patient was cooperative with her treatment and processed information well.  She was not noted to be suicidal or homicidal.  She had two episodes of cutting during the month of treatment.  In each case, she was able to process the information in group and individual therapy and understand the stressors that led her to her decision to cut.  She did not exhibit any behavior problems other than these two incidents that would have required 24-hour medical or nursing care, and on these two occasions, the staff did not directly witness the event or intervene.  All told, mental health residential treatment center services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humatrope 12 mg cartridge for treatment of the enrollees medical condition.Findings:  Two physician reviewers found that Williams syndrome is a genetic disorder resulting from microdeletion of chromosome 7q11.23.  Common characteristics include dysmorphic facial features, global cognitive impairment, supravalvular aortic stenosis, and renal/urinary tract abnormalities. Endocrine abnormalities include short stature, precocious puberty, hypothyroidism, and hypercalcemia.  This patient has been diagnosed with idiopathic short stature, with anticipated adult height significantly below mid-parental height predictions.  Prior to a trial of growth hormone therapy, his height velocity was 4 cm, and increased to 9.27 cm with growth hormone administration.  Williams syndrome is a rare condition, and not all affected patients suffer from short stature, making research on the effects of growth hormone difficult.  This patient has short stature with precocious puberty and advanced bone age.  Despite treatment with Lupron, his growth velocity was very slow. Administration of growth hormone has increased his growth velocity, with possibility that he will achieve a reasonable adult height based on mid-parental height.  Final Result: Two reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in pediatrics and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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

A 36-year-old male enrollee has requested Lyrica 25 mg for treatment of his seizures. Findings:  The physician reviewer found that no comparative trials using gabapentin versus pregabalin (Lyrica) are identified in the literature. Comparison trials of pregabalin versus lamotrigine suggest that Pregabalin has similar tolerability but seems to have inferior efficacy to lamotrigine for the treatment of newly diagnosed partial seizures in adults. Inferior efficacy of pregabalin might have been attributable to limitations in the study design, as treatment doses might have not been optimized adequately or early enough. (Kwan, et al.) In a study comparing gabapentin versus pregabalin, Delahoy, et al. noted In patients with refractory partial epilepsy, pregabalin is likely to be more effective than gabapentin at comparable effective doses, based on clinical response and the number of seizure free days. In sum, while there are no direct comparison trials, the literature suggests that Lyrica is more likely to be effective in this setting than gabapentin. Therefore, Lyrica is medically necessary and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested reimbursement for fentanyl lozenges for treatment of her pain. Findings:  The physician reviewer found that Fentanyl lozenges are presently indicated for breakthrough cancer pain in patients who are opioid tolerant or in patients with a limited life expectancy. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections.