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

A 63-year-old male enrollee has requested prescription medication Celebrex for treatment of back pain.  Findings:  The physician reviewer found that Celebrex has provided good analgesia for this patient in the past, at a relative low dose. All things considered, it is not clinically reasonable to require the failure of two additional non-steroidals when Celebrex is very likely to provide significant symptom relief.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this patients case.  Direct acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America. The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis (F3) or compensated cirrhosis (F4) and those with severe extrahepatic manifestations of hepatitis C.  High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis, and those with coexisting liver disease.  The FibroSure test is recognized as an accurate predictor of fibrosis compared to histologic assessment.  All told, the requested 12-week course of Harvoni is medically indicated 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 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: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested for CyberKnife radiosurgery for treatment of his prostate cancer. Findings:  Two physician reviewers found that a short course of high-fraction radiation treatments that will deliver the biological equivalent to 40 IMRT treatments is well advised considering the radiobiology of prostate cancer. Participation in the CyberKnife clinical trial for the treatment of prostate cancer would be considered optimal treatment according to NCCN guidelines.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested Zofran for the treatment of her nausea and vomiting. Findings:  The physician reviewer found that the patient has had recurrent nausea and vomiting due to underlying comorbid conditions, and she has been tried on multiple antiemetics. These failed to control her symptoms of nausea and vomiting. Because she has responded to Zofran, it is medically appropriate to continue with this regimen.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral upper lid blepharoplasties. Findings:  The physician reviewer found that Hahn and colleagues note that upper lid blepharoplasty is a common procedure that can be performed safely and reliably. In this case, a physical examination and photographs show that the patient has significant dermatochalasis. The patient reports functional deficits related to her decreased vision due to her eyelids. In this clinical setting, the requested services are medically indicated. Therefore, bilateral upper lid blepharoplasties are medically necessary for the treatment of this patient.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 ophthalmology 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

A 36-year-old female enrollee, who has degenerative disc disease at L5-S1, has requested authorization for artificial disc replacement surgery.Findings:  Three physician reviewers found that the proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested laboratory services received during the course of his emergency treatment for medical evaluation of the his episode of diaphoresis and dizziness.   Findings:  The physician reviewer found that based on the available medical records, the comprehensive metabolic panel, CPK, CPK-MB, BNP, troponin, hemogram and platelet count, and prothrombin time were medically necessary.  The above mentioned tests are standard for evaluation of potential causes of pre-syncope. The troponin and CPK and CPK-MB determine whether the patient has suffered an acute myocardial infarction. The BNP assesses congestive heart failure. The CBC checks for anemia, which this patient, being on an anticoagulant would be at risk for, or infection. The chemistry panel assesses hydration status and electrolyte balance. The PT measure the patients warfarin levels. The only test that appears was not medically necessary was the PTT, which is used in patients who are currently taking heparin, or in whom heparin therapy is anticipated. Thus, a portion of the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient behavioral health services for treatment of her behavioral health condition. Findings: The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of subsequent inpatient services. The patient was tolerating medications and medical therapy. Her vital signs were stable and she was not enduring any withdrawal symptoms. The patient's thought process and content were unremarkable. She had supportive family and was active in her treatment. She was assessed as being appropriate for an outpatient dialectical behavior therapy program with continuing ambulatory medical therapy. There was no physician note to review, but the nursing documentation was reassuring as was the psychiatric note.  In sum, the patient remained symptomatic and in need of ongoing specialty care. However, the record indicates that the acute psychiatric syndrome which prompted the initial admission had resolved. Thus, the services at issue were not medically necessary for treatment of the patients behavioral health condition.  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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested services for laser hair removal for treatment of the enrollees gender dysphoria. Facial hair removal is within accepted standards of practice, and clinically appropriate for the treatment of gender dysphoria. The patient was born with genetics to grow terminal hair in predominantly male locations.  It would be abnormal for a female to have terminal hair on the face and chest. Facial hair in a female would be considered abnormal and is referred to hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in areas that are normally found in males. This would include the face and chest. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs and genitalia. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. In this patients case, the requested facial hair removal can provide substantial improvement in the appearance or give the patient a normal female appearance to the extent possible. Moreover, the requested services are likely to improve emotional function for this patient. Therefore, the requested laser hair removal is medically necessary and is reconstructive in nature for the treatment of this patients gender dysphoria.Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested reversal of Lap-band surgery and conversion to gastric bypass surgery for treatment of her upper gastrointestinal symptoms.  Findings:  The physician reviewer found that based upon the medical records, a portion of the requested services is medically necessary in this patients case.  The submitted documentation does not demonstrate the medical necessity of the requested conversion to gastric bypass surgery.  There is no documentation of a multidisciplinary evaluation.  Per the medical records, a multidisciplinary evaluation is needed to establish that this patient is a good candidate for gastric bypass surgery.  With regards to this patients band placement, removal of the adjustable gastric band and port is medically necessary when a patient is symptomatic or if a prolapse is seen on upper gastrointestinal studies in order to prevent secondary complications of erosion, obstruction, or worsening prolapse.  All told, a portion of the requested services is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment for the enrollees attention deficit hyperactivity disorder, anxiety disorder, not otherwise specified, and pervasive developmental disorder, not otherwise specified.  Findings:  The physician reviewer found that in this patients case, residential treatment was not indicated according to current evidence-based practice standards and expert consensus. The study by Wilmshurt involved random assignment of patients into two groups, one of which was treated in the community and the other of which received residential treatment. The residential group had worse outcomes on the whole than the group who remained in the community. In this particular case, the patient was described as cooperative throughout his stay. The incident in question occurred several weeks prior to his admission, and there was no further indication of risk to self or others. Per the submitted documentation, there is a lack of evidence of acute deterioration from his baseline or reasonable expectation that his condition would improve with this level of care.  Additionally, there is a lack of evidence that he failed an alternative level of care, and there is no indication of temporary social stressors which would potentially be improved with residential treatment. The data reviewed in sum fail to establish the medical necessity for residential treatment.  All told, during the dates of service  residential treatment was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xeljanz. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients seronegative rheumatoid arthritis with human leukocyte antigen, B27 (HLA-B27). The submitted documentation does not support the medical necessity of the requested medication. This patient has been diagnosed with seronegative RA. The American College of Rheumatology guidelines recommend methotrexate with or without tumor necrosis factor inhibitors as the next treatment in those who have failed methotrexate alone. There are potential longer-term safety concerns related to tofacitinib that need additional study. There are also multiple studies demonstrating efficacy and safety of tumor necrosis factor inhibitors (TNFi) over the years in treating moderate to severe RA. Per the medical evidence, a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. The medical literature indicates that there is a risk of reactivation of tuberculosis in patients treat with Xeljanz. There is a lack of comparison studies in patients with TB or previous TB demonstrating Xeljanz is safer than TNFi. As such, Xeljanz is not medically necessary for the 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 with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for 108 hours per month of direct applied behavioral analysis (ABA) therapy, 13.5 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 108 hours per month of direct ABA therapy, 13.5 hours per month of supervision and two hours per month are medically necessary for treatment of the patients medical condition. A study evaluated the relationship between ABA treatment intensity and treatment outcomes. The authors found a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made good progress in a relatively short period of time, but he continues to have significantly problematic behaviors in the context of adaptive delays. The peer-reviewed literature supports 25 or more hours of weekly ABA to ensure optimal outcomes. Final Result: The reviewers determined that the requested services at issue are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Stelara SQ (90 mg every 4 weeks).According to a trial conducted by Sands and Marano, Stelara has shown efficacy for the treatment of ulcerative colitis. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response. Moreover, this result was attained in a patient population which was 50% biologic-refractory. Additional studies have demonstrated that Stelara 90 mg every four weeks is safe and well-tolerated for the treatment of inflammatory bowel disease. Patients may respond to dosing every 4 weeks when dosing every 8 weeks is ineffective. In this case, the patient has moderate to severe ulcerative colitis. The patient has had improvement on Stelara. Per the records, he has failed Stelara every 8 weeks, given ongoing inflammation on colonoscopy four months after starting Stelara. Continuation of dosing every 8 weeks may result in complications such as toxic megacolon, dysplasia leading to colorectal cancer, ulcerative colitis flare, hospitalization, need for surgery, or other complications. Therefore, the medical evidence supports a dose escalation to 90 mg every 4 weeks. Discontinuation of Stelara (even if an alternative is initiated immediately) may result in loss of disease control, and subsequent complications. The alternative medication, Xeljanz, is also associated with infectious complications. Thus, the requested Stelara SQ (90 mg every 4 weeks) is medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for amlodipine-olmesartan 5 milligrams - 20 milligrams, taken once a day for treatment of the enrollee who has a history of hyperlipidemia, hypertension and chronic kidney disease. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity of the medication  at issue. Based on the records provided the patient has been diagnosed with chronic kidney disease. There is no documented medication intolerance or allergies to amlodipine-olmesartan. The records also indicate that the patients hypertension is controlled on amlodipine-olmesartan. However, in this patients case there are several preferred formulary alternative medications that are in the same class as amlodipine-olmesartan. The medical literature shows that the formulary alternative medications are equally effective in managing blood pressure. Moreover, there is some evidence that these formulatry alternative medications are equally effective in preventing progression of chronic kidney disease. There is no documented trial or intolerance to any of these preferred formulary alternatives and there is no unique benefit of amlodipine-olmesartan over other medications in the same class that would make continued treatment with Azor medically necessary. Current guidelines for the treatment of hypertension are also in support of benefit based on medication classes without unique benefit of one medication over another within the same class. Therefore based on the records provided, amlodipine-olmesartan 5 mg - 20 mg, taken once a day was not and is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was not and is 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tirosint capsules. Findings:  The physician reviewer found that Recent guidelines of major endocrine societies recommend levothyroxine monotherapy for first-line use in hypothyroidism. While the various tablet forms of levothyroxine have been proven to be safe and effective treatment options for hypothyroidism, a capsule form of levothyroxine, Tirosint, contains no additives, such as lactose, gluten or cellulose, and may therefore be a good option for patients who are unable to tolerate other forms of levothyroxine. In this case, the patient is allergic to most forms of levothyroxine. However, the brand name Tirosint is a levothyroxine treatment that contains no additives or irritants to the patient. Therefore, Tirosint capsules are 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.