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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xeljanz. Findings:  The physician reviewer found that some excellent promise in the treatment of severe alopecia areata. According to the Alopecia Areata Consensus of experts, there was consensus on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and Janus kinase (JAK) inhibition therapy as well as combination therapy of oral corticosteroids together with cyclosporine or methotrexate when used as steroid-sparing. Moreover, Liu and colleagues concluded, Tofacitinib should be considered for the treatment of severe alopecia areata. Additionally, Chapman and colleagues state, Clinical trials and other studies have demonstrated the efficacy of JAK inhibitors in the treatment of a variety of dermatologic conditions. According to the medical literature, the use of Xeljanz (JAK inhibitor) has become the standard of care after patients fail or are no longer able to take steroids for safety reasons. Gilhar and colleagues state that the use of JAK inhibition in alopecia areata constitutes landmark progress in the treatment of this autoimmune disease. Therefore, the requested Xeljanz is medically necessary for treatment of the 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 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 40-year-old male enrollee requested Lyrica for medical treatment of his diabetic neuropathy.  Findings:  The physician reviewer found that while Lyrica (pregabalin) is not considered first-line therapy for diabetic pain, there is adequate literature supporting its safety and efficacy for the treatment of this condition. A placebo-controlled trial of pregabalin by Raskin and colleagues showed that pregabalin was associated with clinically relevant improvement versus placebo in patients with inadequately treated painful diabetic peripheral neuropathy. In this patients case, he failed first-line therapy with Neurontin because of side effects and limited benefit. As such, a trial of Lyrica is medically reasonable and necessary given the patients persistent pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Descovy. In a meta-analysis on the efficacy, safety, and tolerability of tenofovir alafenamide (TAF-Descovy), a study found TAF regimens were non-inferior to tenofovir disoproxil fumarate (TDF-Truvada) regimens and noted advantages in renal function, bone parameters, and lipid profile. Another study found TAF had a similar tolerability, safety, and effectiveness to TDF and probably less adverse events related to renal and bone density outcomes in the treatment of naive and experienced patients with HIV-1. Given that current medical literature does not show that differences between TAF and TDF regimens are clinically significant, the requested medication is medically indicated. Therefore, Descovy 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 infectious 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: Upheld

A 42-year-old female enrollee requested authorization and coverage of  a surgical procedure for the treatment of a bone spur and pinched nerve. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy tablets for treatment of the enrollee's chronic hepatitis B virus (HBV).  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic hepatitis B virus (HBV). Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The submitted documentation supports the medical necessity of the requested medication. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As such, the request to switch the enrollee to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy tablets 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 enrollees 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: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. The submitted records do not support the medical necessity of the requested medication. Essential diagnostic criterion for idiopathic short stature approved by the United States Food and Drug Administration (FDA) is standing height below 2.25 standard deviations for age and gender. In this case, the patient has not met this essential diagnostic criterion for idiopathic short stature. They have not met generally accepted diagnostic criteria for any FDA approved indication for growth hormone therapy, including growth hormone deficiency. Their heights, bone ages, endocrine test results, growth velocities, and growth patterns have been within normal variations and consistent with their twin birth status and their familial pattern of growth and development. Their recent growth spurt was most likely due to their pubertal hormone milieu rather than to exogenous growth hormone. Based on their recent heights and bone age, they are likely to attain a final adult height within the normal range for North American women (above 58.5 inches). Under these circumstances, the requested Nutropin AQ Nuspin is not medically necessary to treat 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 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 patient has requested authorization and coverage for magnetic resonance imaging (MRI) scan of the brain before and after contrast, MRI of the upper spinal canal before and after contrast, MRI of middle spinal canal before and after contrast, and/or MRI of lower spinal canal before and after contrast. The available records document that this patient has undergone extensive neurological evaluation for symptoms including dizziness, postural orthostatic tachycardia syndrome (POTS), and postural headaches. The patient was recently evaluated as part of a multidisciplinary assessment. The patients provider will utilize a heavily T2-weighted MRI of the brain as well as spine for assess for possible cerebrospinal fluid (CSF) leak. Although computed tomography (CT) myelogram is beneficial in the evaluation of patients for suspected CSF leak, it is not utilized as a first-line tool due to radiation, invasive nature of the procedure, and post-procedure headaches. Starling and colleagues evaluated the sensitivity of MRI compared to CT myelogram. The authors concluded that MRI is highly sensitive and noninvasive, which supports its use in the initial evaluation of patients with suspected CSF leak. In this patients clinical scenario, after multidisciplinary discussion and multiple consultations including a CSF leak specialist, the requested MRI examinations are indicated. Therefore, the requested MRI scan of the brain before and after contrast, MRI of the upper spinal canal before and after contrast, MRI of middle spinal canal before and after contrast, and MRI of lower spinal canal before and after contrast are medically necessary for evaluation of 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 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: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested for antibodies screening for evaluation of her loss of balance.   Findings:  Two physician reviewers found that the testing recommended by the patients provider has the potential to assist in the patients diagnosis and treatment planning and is the best available alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 136.95 total hours (to reach 35 hours per week) of direct one-on-one applied behavioral analysis (ABA) therapy and 5.8 total hours (to reach 15 hours per month) of supervision by Board Certified Behavior Analysis (BCBA) provided from for treatment of the enrollees autism. Findings:  The physician reviewer found that the request for 136.95 total hours (to reach 35 hours per week) of direct one-on-one ABA therapy and 5.8 total hours (to reach 15 hours per month) of supervision by BCBA provided was not and is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient is making progress with the current amount of ABA being provided. There is no documentation of aggressive or other maladaptive behaviors that might warrant intensification of ABA services, and there is no indication that maintaining the current amount of direct ABA therapy would result in loss of skills. In addition, the Health Plans authorization of caregiver training will assist the parents in reinforcement of skills acquired in ABA therapy sessions. As such, the request for an increase in ABA hours is not clinically indicated for this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a wearable cardioverter defibrillator for treatment of the enrollees left bundle branch block with an ejection fraction (EF) in the range of 25%. Findings:  Two out of three physician reviewrs found that the role of the implantable cardioverter defibrillator (ICD) in patients with significant left ventricle dysfunction is well documented. Similarly, the wearable cardioverter defibrillator has been shown to be an appropriate strategy in subsets of patients awaiting permanent ICD placement. However, this patient does not meet the criteria for ICD placement since she does not present with high risk factors for sudden cardiac death such as severe ambient ventricular arrhythmias, recurrent syncope, or advanced heart failure. Final Result: The reviewers determined that the requested wearable cardioverter defibrillator 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: Reviewers number 1 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Reviewer 2 is board certified in internal medicine with sub-specialty certification interventional cardiology and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the American College of Radiology (ACR) position statement on breast tomosynthesis advocates removing the technique from the list of investigational tools, based upon the value the technique brings to providers in the interpretation of breast exams.  The value is due to the ability of providers, when using this technique, to separate out glandular elements of the breast from underlying architectural distortion which, in turn, has led to an associated decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic views was likely of more benefit to this patient than if the mammogram had been done with 2D technique alone.  Final Result: Two 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: Urgent Care
Decision: Upheld

A 62-year-old female enrollee has requested ophthalmology services for treatments of her cataracts. Findings:  The physician reviewer found that this patient was previously diagnosed by her ophthalmologist as having cataracts in both eyes that required surgery.  In a letter from the patient, she states that she was told that surgery was an urgent need. The patient also reports that she had a history of visual blackouts, which were diagnosed as probable visual migraine. The medical records indicate that the patient underwent successful cataract surgery in both eyes. The patient had left eye cataract surgery on the date indicated and right eye cataract surgery on the date indicated. Cataract surgery is performed on a non-urgent, elective basis and is not an urgently required procedure. In this case, the patient presented to the ophthalmologist for evaluation of blackout symptoms, but once the vision problem was attributed to cataract, a prudent layperson would not have believed surgical treatment was urgently needed to prevent serious deterioration of ones health. All told, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. A relatively new test, the Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the Afirma Gene Expression Classifier testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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 endocrinology and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Orencia for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Orencia is not a standard treatment for lupus nephritis and is not generally utilized unless there is refractory disease.  In this case, the patient has refractory disease and requires a medication that is off-label. Given that the patient has not responded to steroids, CellCept and Cytoxan there are limited options in decreased nephritis damage and the possibility of dialysis secondary to renal failure. In addition, there is literature supporting the safety of Orencia in the treatment of lupus with limited data on efficacy. Based on the clinical documentation submitted for review, the requested medication is medically necessary for treatment of the 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 physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for motor cortex stimulation, deep brain stimulator, or spinal peripheral stimulator. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees trigeminal neuralgia. Findings: The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of peer-reviewed studies that show the use of peripheral nerve stimulation results in long-term benefit. A study  performed a retrospective review of the medical records on patients who were trialed and implanted with occipital nerve stimulator (ONS) systems at one institution. These results, although limited by their retrospective nature, suggest that ONS can be effective long-term despite technical challenges. However, the number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Another study noted that larger studies are needed to demonstrate the effectiveness of nerve and brain stimulation for facial pain syndromes. In addition, there are no U.S. Food and Drug Administration (FDA) approved peripheral nerve stimulator devices for trigeminal neuralgia. Given the lack of support in the peer-reviewed literature, the request for motor cortex stimulation, deep brain stimulator, or spinal peripheral stimulator has not been established as medically necessary for treatment of the patients trigeminal neuralgia. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in neurology 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.