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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy solution auto-injector 0.25 mg/0.5 ml.Findings:  The physician reviewer found that current medical evidence supports the requested medication in this clinical setting. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies that are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss. Therefore, Wegovy solution auto-injector 0.25 mg/0.5 ml 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other modalities.  The use of breast tomosynthesis with digital mammography has been associated with an increase in detection of small cancers.  In addition, the post lumpectomy breast is very challenging to evaluate and the addition of tomosynthesis helps the radiologist discern between normal post lumpectomy scar and post radiation changes and possible tumor recurrence/residual.  All told, the superior efficacy of digital breast tomosynthesis has been established.  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: All three reviewers are board certified in diagnostic radiology 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

A 44-year-old female enrollee requested Humira for medical treatment of her hidradenitis suppurativa.  Findings:  The physician reviewer found that in this patients case, the requested medication is likely to be more effective than other treatment options.  This patient has failed multiple therapies, including oral antibiotics, topical antibiotics and intralesional steroids.  Effective treatment of hidradenitis is very challenging.  Given that the patient has already failed typical first-line therapies, treatment with Humira is appropriate.  Thus, Humira is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name Qualitest Norco instead of brand name Mallinckrodt Norco for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that There is a lack of support in the medical literature for the requested brand name medication in this patients case. In the documentation available for review, the patient reported that Norco manufactured from Mallinckrodt causes her chest and arm pain. The record notes that this patient is taking the 5/325 mg of Mallinckrodt Norco and is exposed to two substances that the Qualitest brand does not have in its 5/325 mg formula, namely crospovidone and colloidal silicon dioxide. While the literature suggests that Norco from Mallinckrodt contains less inactive ingredients than Norco from Qualitest, this only applies to Norco 10/325 mg dosage. It is also noted that povidone is found in both brands, making crospovidone less likely the problem. In addition, while both of these substances are known in the medical literature to cause allergies, it is only in rare cases. In this patients case, it is unclear from the records if she has an allergy to these substances. There is a current recommendation to perform allergy skin testing to see which substances she may be allergic. In addition, the medical literature recommends that skin testing should be completed due to the possible concern of a hypersensitive state to crospovidone and/or colloidal silicon dioxide, as they are found in the Norco from Mallinckrodt. Only upon confirmation of immediate reading skin tests and/or delayed reading skin testing that is positive for an allergy to crospovidone and/or colloidal silicon dioxide would Qualitest 5/325 mg of Norco be medically necessary. Therefore, at this time the requested authorization and coverage for brand name Qualitest Norco instead of brand name Mallinckrodt Norco has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that requested medication brand 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ingrezza for treatment of the enrollees tardive dyskinesia. Findings:  The physician reviewer found that there is a lack of support in the documentation for the medical necessity of the requested medication in this clinical setting. It is unclear if this patients involuntary movements are tardive dyskinesia. Tardive dyskinesia is one differential for involuntary movements. However, other treatment options should be explored prior to prescribing Ingrezza. For example, amphetamines are known to cause involuntary movements. Discontinuation of amphetamines would be considered a first step. Subsequent urine toxicologists should be performed to rule out amphetamine and other substance of abuse. Additionally, the chart notes indicate that the patient has memory problems. However, there is no explanation in the notes for the memory loss. In combination with involuntary movements and absence of stimulants, the differential remains wide including Parkinsons disease, Huntingtons disease or other neurological syndromes. As such, the medical records do not support the use of Ingrezza as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 enrollee has requested reimbursement for the specialized laboratory testing for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti- infliximab antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. However, there are few well controlled clinical trials to confirm that use of the Prometheus Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. According to the American Gastroenterological Association (AGA) guideline recommendations on therapeutic drug monitoring (TDM) in patients with inflammatory bowel disease (IBD) treated with anti-TNF agents, there currently exists no defined cut-offs by which to judge low versus high titer anti-drug antibodies. Given that Prometheus Anser IFX testing has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, the specialized laboratory testing 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 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 internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Upheld

A 22-year-old female enrollee has requested for emergency services for treatment of her rash. Findings:  The physician reviewer found that this patient did have a sudden onset of symptoms. Although she was experiencing itching, she was not experiencing any shortness of breath, airway compromise, or difficulty swallowing. She had not attempted any over the counter medications or treatments prior to seeking treatment in the emergency department.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 12-year-old male who in December 2003 had a height standard deviation of 2.95 and a significantly delayed bone age. Provocative stimulation testing was performed in January 2004, which ruled out growth hormone (GH) deficiency. It was noted the patients serum IGF-1 and IGFBP-3 markers for growth hormone action were in the lower quartiles for age and sex. The patient was started on growth hormone therapy and grew two inches in a three-month period. A request has been made for continued growth hormone therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients diagnosis.Though the patient is short for his age at 3 standard deviations (SD) below mean for age, his stature is not inconsistent with mid-parental and target heights (within 1 SD). His projected final height at age 11+4 with a height of 126cm and a bone age of 9 years is 63.6 inches. Prior growth measurement has not been included so the patients baseline growth rate is not known.The patients mid-parental height is actually less than -2.5 SD at 64.5 inches. In the absence of evidence of a preceding abnormal growth velocity, it appears the patients present and predicted short stature is more consistent with a genetic etiology and thus, is not idiopathic. As such, growth hormone therapy is not medically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female with apparent panic disorder. She has been treated with Klonopin in both pill and wafer form. The patients current dosage of Klonopin is unknown. The patient has requested authorization and coverage for Klonopin wafers for rapid treatment of panic symptoms. The Health Plan has denied the request on the basis the requested medication is not medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient may be undertreated with the pill form of Klonopin at present. Usually, Klonopin is absorbed in 1 to 4 hours with a 30 to 40 hour elimination half-life, making it a long-acting benzodiazepine. Furthermore, other medications (e.g., SSRIs, tricyclic antidepressants, mood stabilizers) could be used in addition to therapy for relaxation techniques. Moreover, there is no evidence the patient has difficulty swallowing pills. Thus, there is no medical indication for the use of Klonopin wafers in this case. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial hair removal for treatment of the enrollees gender dysphoria.  Findings: The physician reviewer found that the requested services are medically indicated in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Facial hair in a female would be considered abnormal and is referred to hirsutism. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested services are going to improve emotional function for this patient. These treatments will create a more feminine facial appearance. Therefore, the requested facial hair removal is medically necessary. For the reasons stated above, the requested services are reconstructive in nature and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are reconstructive in nature and 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the knee for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, a trial of conservative treatment is appropriate, as acute pain will often resolve without more aggressive intervention.  It is not unreasonable for him to be evaluated by an orthopedist.  The primary reason to obtain an MRI is in preparation for surgery, which the patient may need.  This patient has had symptoms for over one year, has not had any recent trauma, and there is no indication that he has an infection or other condition that might demand immediate evaluation.  At this time, there is a lack of support for the requested MRI of the knee in this clinical setting.  All told, the requested MRI of the knee is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

A 51-year-old male enrollee has requested for Provigil 200mg for treatment of his condition. Findings:  The physician reviewer found that this patients depression is quite serious, and his response to Provigil augmentation has been established. The depression recurred when the Provigil was discontinued. The use of a psychostimulant to augment treatment of antidepressants is well-established. Provigil has benefitted this patient, and he has demonstrated a specific need for Provigil to reduce and maintain his depressive symptoms.
Appeal type: Medical Necessity
Decision: Overturned

The parents of an eight-week-old male enrollee requested authorization and coverage of a referral to a specialized center for the diagnosis, treatment, and management of complications from spina bifida. The Health Plan denied the request indicating that the requested referral is not medically necessary for the treatment of the enrollees spina bifida.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient qualified for ASAM Level III treatment, similar to the services provided at the RTC. Given the severity of the patients illness, the RTC services were medically necessary for 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 psychiatry with expertise in addiction 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 17-year-old male enrollee has requested  acute inpatient psychiatric treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found the patient had failed less restrictive interventions and presented after making homicidal threats to his parents. The records indicate there was concern of a budding formal thought disorder in this previously high-functioning young man. The patient was initially resistive to all inpatient treatments and unable to entertain parental visits. However, he has made progress during the hospitalization. On specified date, the patient had a constricted affect and poor insight. The team was actively cross-tapering psychotropic medication. On the date indicated, the patient was socializing with peers and adhering to ward routines. The patient was able to tolerate visits from both parents. He was participating in some groups and inviting the physician to discuss the anxiety of a fictional character. He remains symptomatic and psychiatrically ill. In sum, the acute inpatient services are expected to improve the patients condition, prevent a more serious health condition, and clarify diagnoses. The treatment is safe, appropriate and consistent with the American Psychiatric Association (APA) guidelines. Thus, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25% (Feldman & Messick). Extensive review of the literature, including the meta-analysis by Law, et al. noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman & Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment (Feldman & Messick). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. Statistically greater improvement was found with intensive direct speech and language therapy delivered by speech and language therapists over an eight month period, when compared to no intervention or nursery-based intervention (Gallagher, et al). Speech therapy in this patients case is medically necessary.