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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for lidocaine 5% patches.A review of the U.S. Food and Drug Administrations (FDA) Drug Information on ZTLIDO (lidocaine topical system) states that the lidocaine patch is only approved for use in treating post-herpetic neuralgia. A review by McColgan and colleagues states that there has been no evidence to support the use of lidocaine patches for musculoskeletal pain. A systematic review completed by Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors reviewed seven studies and concluded, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. In this case, the patient has been diagnosed with cervical radiculopathy for musculoskeletal back pain. Currently, the FDA has not approved the patches for this use, and the recent reviews on this subject reinforce the lack of evidence for use of the lidocaine patches in musculoskeletal related chronic pain. Thus, the requested lidocaine 5% patches are 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with idiopathic pulmonary fibrosis (IPF). The patient had a chest CT scan that found interval extensive progression of pulmonary fibrosis, with increased extensive honeycombing in the bilateral lower lobes, left greater than right, especially in the sub-pleural left lower lobes medially and right lower lobe. The CT scan also revealed an increase in honeycombing in the left upper lobe anteromedially, and to a lesser extent to the anteromedial sub-pleural right upper lobe. The patient was seen for evaluation of idiopathic pulmonary fibrosis. The patient had mild symptoms of coughing with breathlessness. Ultimately, the patient was noted as having dry inspiratory crackles on the physical exam. A chest x-ray was noted to be consistent with reticular opacities. The patient was noted to have had a good exercise test which revealed mild desaturation with significant activity. The patient was noted to have remained extremely active despite their condition. The patient was noted to have a desire to avoid skin hypersensitivity, and was then placed on OFEV in order to avoid potential skin hypersensitivity reactions with Esbriet. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) has approved nintedanib (OFEV) for the treatment of idiopathic pulmonary fibrosis. In addition, the 2015 American Thoracic Society (ATS) Clinical Practice Guideline for the Treatment of Idiopathic Pulmonary Fibrosis provides a conditional recommendation for the use of nintedanib in individuals with idiopathic pulmonary fibrosis. In this case, the patient has been diagnosed with confirmed IPF based upon CT and pulmonary function testing. As the U.S. Food and Drug Administration has approved this medication for treatment of IPF, and current medical literature recommends this medication for IPF, the requested OFEV (nintedanib) is substantiated and supported by literature. Under these circumstances, OFEV 150 mg capsules are medically necessary for treatment 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 internal medicine and subspecialty in pulmonary diseases 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 patient is requesting authorization and coverage for direct applied behavior analysis (ABA) 1:1 10 hours per week, two hours supervision/month, six hours treatment planning/month and two hours parent training/month. The patient is diagnosed with autism spectrum disorder, mild intellectual disability and an unspecified communication disorder. While the patient has made progress and has had a history of receiving ABA services previously, to draw the conclusion that the gains were due to outpatient therapy are purely correlational. There is no evidence base for individuals benefiting from outpatient therapy with a diagnosis of autism with comorbid intellectual disability, while there is an abundance of research on the effectiveness of ABA therapy for these same individuals. The psychologist who reaffirmed the patients autism diagnosis, recommended ABA therapy but did not recommend traditional outpatient therapy. While the patient was receiving outpatient therapy, they were also receiving ABA therapy, thus progress on any goals are likely attributed to ABA therapy. In this case, 10 hours of ABA per week are considered focused intervention, with an emphasis on treating specific areas for an individual versus a broad treatment, attempting to ameliorate most, if not all, autism symptoms simultaneously. The providers request is well within the BACB guidelines, as assessment and treatment methods are clearly outlined. ABA is the most evidence-based treatment for the patient on the autism spectrum. Therefore, these services are medically necessary, and the Health Plans decision should be overturned.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 psychology 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

An 18-year-old male enrollee has requested child/adolescent psychiatric residential treatment for treatment of his behavioral health problems. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity for child/adolescent psychiatric residential treatment during the time frame in question . While the patient did not progress satisfactorily in individual treatment, there was no indication that alternatives were considered, such as intensive outpatient treatment.  Additionally, it is not apparent that aggressive medication management was attempted. Furthermore, the records submitted from the facility did not indicate that the patient required or received timely services commensurate with those expected in a residential setting.  For example, the initial evaluation appeared to take place one month after the patient was admitted, and there is no additional evidence of intensive multidisciplinary team work with multiple hours of programming on a daily basis. American Psychiatric Association practice guidelines indicate that patients should be treated in the least intensive setting which is likely to be safe and effective. There is no indication in the record that the patient could not have been safely and effectively managed on an ambulatory basis.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 29-year-old enrollee has requested facial laser hair removal. Findings:  The physician reviewer found that the patient has a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2010. The patient reported that the facial hair limits their ability to be perceived as female and negates their gender identity. The patients symptoms of gender dysphoria are reportedly exacerbated when they were mis-gendered due to the presence of facial hair. The patients mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. Guidelines for the medical necessity of facial feminization surgery (FFS) exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the classification of laser hair removal as medically necessary, the WPATH states that, in addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude  as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. Kalra and colleagues reported that on surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include facial and body hair removal. The authors noted that these procedures serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on this patients documented history of gender dysphoria, the requested facial laser hair removal is supported as medically necessary. 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 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

A 44-year-old female enrollee has requested the prescription medication Elidel 1% cream for the treatment of her skin condition. Findings:  The physician reviewer found that a topical corticosteroid could have been used for this patients contact dermatitis.  There is no literature to suggest that a topical corticosteroid impedes healing more than Elidel. Although Elidel may have addressed the patients condition, a topical corticosteroid would have been considered first line therapy and would have been appropriate for treatment of the patients condition.  In addition, no evidence has been submitted as to why corticosteroids may have been contraindicated in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for a cold therapy machine. Given the information provided, the patient underwent an arthroscopic posterior cruciate ligament (PCL) reconstruction and meniscal repair. As part of her post-operative regimen, the provider recommended a cold therapy machine. Per the current peer-reviewed medical literature, cold therapy machines can help with immediate post-operative pain. However, there is minimal evidence that a cold therapy machine decreases narcotic usage or leads to a better functional outcome. Overall, standard ice packs have been shown to produce the same clinical results in the long-term. Accordingly, the requested cold therapy machine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two of the three physician reviewers found the requested cold therapy machine is not 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery with expertise in pediatric orthopedic surgery 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 38-year-old male enrollee has requested chemical dependency inpatient detoxification for the treatment of his chemical dependency. Findings:  The physician reviewer found that the patient does indeed have a serious and long-standing chemical dependency issue; he was in need of detoxification at the time of his admission. However, I concur with the Health Plan that he did not meet criteria for treatment in a chemical dependency inpatient detoxification program. His symptoms were not sufficiently severe and he did not require 24/7 supervision as provided at that level of intervention. There were no associated clinical complications requiring an inpatient level of care. As such, the patient could have been effectively and safely treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female has requested approval for nerve conduction velocity (NCV) studies and testing, electromyography (EMG), genetic marker testing, Minnesota Multiphasic Personality Inventory (MMPI), 16 PF Questionnaire (Personality Factors), Milan Multi Axial Clinical Inventory 2, a face-to-face neuropsychological screening, and a second opinion outside of Loma Linda University Healthcare System for evaluation of her behavioral health issues.   Findings:  The physician reviewer found that the available medical records provided for review support the medical necessity of a second opinion from an independent neurologist for evaluation of the patients movement disorder. However, the records do not support a request for NCV testing, EMG, genetic marker testing, Minnesota Multiphasic Personality Inventory, personality factor test, Milan Multi Axial Clinical Inventory 2, or face-to-face neuropsychological screening. The records indicate the patient has movement disorder which has been assessed by the provider as a myoclonus condition. A second opinion is appropriate in order to assess and provide opinion as to the neurologic basis of the patients condition and confirm etiology as this is not established in the medical records provided for review. As the records do not document any abnormal motor, sensory, or reflux abnormalities, the NCV testing or EMG are not clinically indicated. In addition, these tests are not necessary for the general evaluation of a tremor or myoclonus. Further, the requested psychological or psychiatric evaluation is not supported with regard to evaluation of the patients myoclonus or neurologic condition. The patient has an established diagnosis regarding her psychiatric condition. Additional personality and psychological testing is not supported to evaluate for any neurological condition and is not supported for evaluation of myoclonus. Therefore, the requested second opinion with a neurologist in regard to the reported movement disorder is supported as medically necessary, while the additional services are not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested for the medication Lamisil for treatment of his onychomycosis.  Findings:  The physician reviewer found that there are other treatments and medications available that should resolve his asymptomatic infection.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Zoloft for treatment of her behavioral health condition. Findings: The physician reviewer found that Zoloft is a serotonergic enhancing medication approved by the U.S. Food and Drug Administration (FDA). Zoloft remains just one of two medicines today approved by the FDA to treat PTSD. The generic name for Zoloft is sertraline. There is potential for bioavailability variance when a generic medication replaces a brand name. On rare occasions, the possibility exists that differences in potency may underlie adverse changes in clinical status (Sussman). In this case, the patient is treated with a medication FDA approved for her two psychiatric diagnoses. She previously decompensated when prescribed generic sertraline. The medical record indicates that this patient has intolerance to Depakote and Zoloft generics. Therefore, brand name Zoloft is medically necessary and safe, appropriate and reasonably expected to both improve the patients condition and prevent an exacerbation of the illness burden.    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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the genetic testing (gene expression profiling) provided on 10/5/16. The Health Plan has denied this request indicating that for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma Assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2. The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. Therefore, DecisionDx-Melanoma Assay signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. The patients recent growth pattern indicates that catch-up growth is unlikely without somatotropin (brand name Nutropin AQ) therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nutropin AQ is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of patients aged six years and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. One study notes that moderate-to-severe atopic dermatitis is defined as involving over ten percent of BSA and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Another study notes that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and is not recommended for younger children. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the provider reports that the patient has moderate-to-severe atopic dermatitis affecting over ten percent of his BSA. The patient had tried and failed topical steroids including betamethasone, tacrolimus, Eucrisa, Opzelura, and prednisone, a systemic steroid. In this clinical setting, the requested medication is medically indicated. Therefore, Dupixent is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.