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

The patient is a seven-year-old female with Type I Diabetes who previously achieved glycemic control through the use of an insulin pump. The record indicates that despite blood glucose testing eight to ten times daily, her hemoglobin A1c had risen from 6.5% in 2003 to 7.2% in August 2005. The DexCom system was prescribed to improve the patients glycemic control and was implemented in May of 2006. The patients provider reported better blood glucose control with the DexCom system and improved detection of hypoglycemic and hyperglycemic episodes. The parents request for reimbursement for the cost of the device was denied by the Health Plan citing a lack of medical necessity.The patients hemoglobin A1c level falls outside of the hemoglobin A1c goals recommended by the American Diabetes Association (7.0%) and the American Academy of Clinical Endocrinologists (6.5%).  Her provider also reports she has had a number of hypoglycemic episodes (less than 60mg/dl) detected at night with the use of the DexCom system for the initial month. The device has recently been approved by the FDA for use in adults. The DexCom system is not intended to replace glucose monitoring by finger stick. The providers letter indicates that the problems with hypoglycemia have improved with the use of the DexCom device and that low readings on the monitor are appropriately verified by finger stick before action is taken. Hypoglycemia remains a significant limitation in children when their caretakers attempt to achieve better glycemic control, in line with the above recommendations. The risks associated with hypoglycemia can be minimized through the alarm feature of the DexCom system. The DexCom STS Continuous Glucose Monitoring System is a medically appropriate adjunct to the insulin pump and blood glucose testing by finger stick previously employed.Based upon the information set forth above, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Synthroid. The goals of treatment of hypothyroidism include alleviation of symptoms and normalization of serum thyroid-stimulating hormone (TSH) levels. Once initiated, the TSH should be monitored and levels rechecked in four to six weeks with each dose change until the patients TSH levels have normalized with alleviation of symptoms. Treatment of hypothyroidism is straightforward with thyroid replacement therapy consisting of tablets, gel, and liquid agents. With tablets, there are brand name and generic formulations. Based on current medical literature and guidelines, generic formulations may be bioequivalent to branded formulations, but they may not be therapeutically equivalent. Therefore, it is important to titrate any dose of medication whether branded or generic. This patient has a history of Hashimotos thyroiditis with resultant hypothyroidism. Her treatment with initiated with brand name Synthroid with good response and alleviation of her symptoms. When she was switched to the generic formulation, levothyroxine, at the same dose, her symptoms reportedly recurred. However, no follow-up laboratory testing was performed to determine her TSH levels. Moreover, there were no reported trials of titrating her dose based on laboratory testing of TSH levels. The patients symptoms are likely to improve on generic levothyroxine with readjustment and titration of dosage. The records support an increase of the patients generic levothyroxine dose based on TSH levels to help alleviate her symptoms, but there is a lack of support for brand name Synthroid. Accordingly, the requested brand name Synthroid is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammaplex, or in the alternative, Octagam. Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss. This patient has chronic immune sensory polyradiculopathy (CISP), a sensory variant of CIDP, that is progressive and more debilitating. CISP is a condition that presents with sensory neuropathy, ataxia, and normal nerve conduction from selective sensory nerve root inflammatory demyelination. According to the evidence-based guideline by the American Academy of Neurology, IVIG is effective and should be offered in the long-term treatment of this patients medical condition. Thus, the requested Gammaplex is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Gammaplex is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Overturned

A 61-year-old male enrollee has requested an AutoMed 3400 infusion pump and services related to the initiation and discontinuation of the infusion of 5-FU in the prescribing physicians office for the treatment of his rectal cancer. Findings:  The physician reviewer found that it is medically necessary for this patient to utilize the smaller infusion pump and to have his infusion services at his doctors office.  The requested pump is smaller in all aspects, including needle size, fluid requirements and weight. These factors make it the better medical option for administration of the chemotherapy. It is safer and more effective for this patient than other available infusion pumps. Based upon the patients history and current condition, it is also medically appropriate for the patient to receive these infusion services at his physicians office.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested IVIG therapy for the treatment of his condition. Findings:  The physician reviewer found that the stated need for IVIG is based upon borderline low levels of IGG and a host of other studies. These latter studies do not represent the standard evaluation of chronic fatigue/chronic infection and are not well-accepted by practicing allergists/immunologists. There is no documentation of a sinus CT to document a sinus infection. The submitted documentation does not support the need for IVIG therapy for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the gene test performed for evaluation of the enrollees breast cancer. Findings:  Two physician reviewer found that the decision regarding the use of adjuvant chemotherapy is generally based on the pathologic details of an individual patients breast cancer, as well as genetic analyses in certain situations. The most commonly used assay is Oncotype, though MammaPrint is also used as an alternative. There is good correlation between these genetic assays and prognosis, and both have been used as aids in the adjuvant chemotherapy decision. However, the BluePrint assay is not designed to predict prognosis but rather it defines what subclass of breast cancer, such as Luminal A, B or other. This determination is of interest, but not useful in making treatment decisions and has not been demonstrated to be clinically beneficial. Furthermore, in this case, the subclass is most likely Luminal A based on the pathologic details, thus additional testing for this determination was not indicated. Accordingly, the MammaPrint portion of the gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the BluePrint portion of the gene test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the testing at issue was 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 31-year-old male enrollee has requested 30 sessions of aquatic therapy for treatment of his spinal cord injury.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested therapy. This patient has progressed well with physical and occupational therapy and is independent at wheelchair level. While the patient was working on standing in physical therapy, this is not a functional task at this time. Aquatic therapy is not a standard of care modality in this setting and is not considered medically necessary for this pathology. There is no documented medical indication for aqua therapy at this time. All told, it is not medically necessary that the patient receive the requested 30 sessions of aquatic therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the abdomen/pelvis (CPT 74178) and CT scan of the head (CPT 70470). The records provided for review demonstrate that this patient was diagnosed with breast cancer in 2009 and she is status post modified radical mastectomy and adjuvant systemic chemotherapy. The records document that she has a history of transaminitis and fatty infiltration of the liver. The patient presented to her provider in June 2020 with complaints of pain in the right shoulder blade region, mid back, hips, and knees. In this clinical setting, the provider recommended imaging studies as dictated by the physical findings and patient symptoms, not for routine follow-up. Given these findings, the requested CT scan of the abdomen/pelvis (CPT 74178) and CT scan of the head (CPT 70470) are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested a magnetoencephalography (MEG) scan for an evaluation of her epilepsy. Findings:  Three physician reviewers found that the medical literature shows that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci. The American College of Radiology notes that MEG can be an effective tool for localization of seizure foci in patients with medically refractory partial epilepsy. Due to the life-threatening nature of the patients seizure disorder and the inability of standard diagnostic testing to adequately identify her seizure focus, MEG should be approved for this patient, as it is an appropriate tool in the non-invasive pre-operative evaluation of potential candidates for epilepsy surgery.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-five year-old male who has an asymmetric prostate with a nodule on the right lobe is requesting a referral for out-of-network brachytherapy services as he feels the wait for in-plan services would be too long.Reviewers Findings: The reviewing physician found that the patient is concerned that a delay in treatment will jeopardize his health. The Health Plan is following current, accepted standard of care and there is nothing in the record indicating that the physicians who have been involved in the care to date are not following national guidelines. Furthermore, the patient is not in the high risk category but rather in the low recurrence risk category based on NCCN guidelines.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for Restasis, clear contact eye patch treatment and Latisse for treatment of her corneal erosion and blepharitis. Findings:  The physician reviewer found that Restasis is used in the treatment of aqueous deficiency dry eye, not recurrent corneal erosions.  As described by Pflugfelder and colleagues, Restasis inhibits T-cell activity, thereby inhibiting the immune-mediated inflammation causing dry eye.  Its mechanism of action does not include improving corneal epithelial adhesion to the underlying basement membrane.  The current medical literature does not support the use of Restasis for the treatment of recurrent corneal erosions or EBMD.  Additionally, the requested clear contact eye patch treatment is not medically necessary for the patients condition.  The safe and effective use of a bandage contact lens requires good doctor-patient communication and good patient compliance because of the potential for sight-threatening infection.  The submitted documentation fails to establish the medical necessity of the requested clear contact eye patch treatment. Latisse, or bimatoprost 0.03% solution, is a prostamide medication originally approved for use in glaucoma, but observed to have the unusual side effect of increasing eyelash length. As noted by Law, bimatoprost is effective in promoting growth of healthy eyelashes. There is a lack of medical literature supporting the safety and efficacy of bimatoprost when eyelid inflammation from chronic blepharitis is present, as it is in this case. Additionally, Restasis and clear contact eye patch treatment are not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 19-year-old male enrollee requested inpatient hospitalization services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a systemic developmental disorder coupled with concerning cognitive impairment and disruptive behavior with prominent self-injurious behavior that dominate all domains of functionality. In reviewing the clinical documentation, the patient had not consolidated the treatment gains needed to succeed in a less restrictive setting and that discharge would have resulted in undue morbidity and likely readmission.  The multidisciplinary and evidence-based services provided were for active treatment that was delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The services were reasonably expected to improve his condition and prevent a more serious episode of illness. All told, the services at issue were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 54-year-old male who is unable to obtain a penile erection without the use of medication. He has medical evidence of hyperlipidemia with a triglyceride level of 165 (normal is up to 150) in January 2004. He is seeking authorization for Viagra for treatment of his erectile dysfunction.Hyperlipidemia is a recognized and documented cause of organic erectile dysfunction. Treatment with PDE-5 inhibitor medications is accepted primary therapy for treatment of erectile dysfunction and is often successful. If not contraindicated by concomitant use of organic nitrates or drug intolerance to the medication, the patient should be treated with Viagra. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested Lariat procedure for treatment of his risk of stroke.  Findings:  Two physician reviewers found that this patient does not qualify for the requested Lariat procedure for several reasons. He is not in atrial fibrillation and the likelihood of relapse is low. Subconjunctival hemorrhage history occurs in non-anticoagulated patients and does not constitute a high risk event. Given the records provided for review, anticoagulation was no longer necessary after the one year success of the PVI with atrial fibrillation ablation. The finding of delayed LAA emptying and lower LAA velocity is not mentioned as a risk variable and while noted at the time of PVI ablation, this was not reproducible later on. A variety of studies on the Lariat device and similar devices have failed to show benefit in this clinical setting. This procedure in patients in sinus rhythm who are one year post ablation is not a proven or accepted treatment in the medical community. All told, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for transcranial magnetic stimulation (TMS) treatment. Carmi and colleagues describe obsessive-compulsive disorder (OCD) as a chronic and disabling disorder with poor response to pharmacological treatments. Using the Yale-Brown-Obsessive-Compulsive Scale (YBOCS) to measure clinical response to treatment, the authors found that treatment-resistant OCD participants treated with high-frequency deep TMS experienced an alleviation in OCD symptoms. The U.S. Food and Drug Administration (FDA) has approved the use of TMS for the treatment of OCD. In this case, the patient has undergone multiple treatment trials, without response. Therefore, TMS treatment is likely to be more beneficial for treatment of this patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Methadone HCL tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation does not support the medical necessity of the requested medication. In this case, the patient reports taking Methadone 3 times daily for pain and has been taking this medication for over 5 years. There is no evidence in the medical records provided of prior attempts at long acting opioids, and there is no evidence of a signed opioid contract or evidence of random urine toxicology for compliance. Furthermore, there is no documentation of percent relief, duration of relief, or improvement in function with the use of this agent. Under these circumstances, the requested medication, Methadone HCL tablets, is not medically necessary for treatment of the 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for urine tests (albumin to creatinine ratio (ACR) and glomerular filtration rate (GFR)).McTaggart and colleagues state that albuminuria is an important sign of chronic kidney disease and is detected routinely by measurement of urinary ACR. Additionally, Ranch states that proteinuria in certain conditions can signify renal disease and worse outcomes. Given the patients VSD, thalassemia, and potential hepatorenal issues, evaluation of renal function is essential for subtle defects that require early medical intervention. Urinalysis results and serum creatinine are not adequate for detection of minor defects early in a disease process. Therefore, formal GFR and ACR are needed to assure proper care, particularly when a history of abdominal pain of unknown etiology exists. Therefore, the requested urine tests (ACR and GFR) are medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 urology with sub-specialty certification in pediatric urology 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.