Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested for laboratory testing for evaluation of his risk of cardiovascular disease.   Findings:  Three physician reviewers found that current guidelines still do not support routine measurement of inflammatory markers for the purpose of modifying LDL goals in primary prevention. Routine screening for homocysteine also remains controversial. Although routine screening for elevated homocysteine is not yet recommended, it may be advisable for individuals who manifest atherothrombotic disease that is out of proportion to their traditional risk factors or who have a family history of premature atherosclerotic disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pradaxa 150 mg twice daily. The records provided for review document that this patient has a history of DVT and saddle pulmonary embolism. The patient has been successfully and safely maintained on Pradaxa since his diagnosis of DVT and saddle pulmonary embolism 2019. The patients provider has recommended continued treatment with Pradaxa. The U.S. Food and Drug Administration (FDA) has approved Pradaxa for the treatment and prevention of DVT and pulmonary embolism in patients at risk for recurrence. In addition, the American College of Chest Physicians (ACCP) and American Family Physicians (AFP) support treatment with Pradaxa for the prevention and treatment of DVT or pulmonary embolism (Wigle, et al.). Schulman and colleagues found that Pradaxa was effective in the extended treatment of venous thromboembolism and carried a lower risk of major or clinically relevant bleeding than warfarin. Moreover, Ageno and colleagues found that in phase III studies, Pradaxa was as effective as, and significantly safer than warfarin. Given this support, the requested Pradaxa 150 mg twice daily is medically necessary for 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 subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-eight year-old male with renal cell carcinoma is requesting reimbursement for laparoscopic cryoablation.Reviewers Findings:  The reviewing physician found that thermal ablative techniques of cryoablation and radiofrequency ablation have major limitations including uncertain tumor destruction and inadequate documentation of long-term cancer control.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: All 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Adderall XR for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that Adderall XR is a psychostimulant medication used to treat ADHD.  It is composed of 50% immediate-release beads and 50% delayed-release beads designed to mimic the effects of two doses of immediate release Adderall given four hours apart.  The medication can have potent effects on neurotransmission and addictive neural circuits with subsequent untoward psychiatric side effects.  Adderall is well-known to be activating to the point of causing irritability and behavioral disinhibition.  Per the medical records, it appears that the patient experienced negative side effects while on the medication previously.  All told, the requested medication Adderall XR is not medically indicated 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 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 requested coverage for the injection, onabotulinumtoxina, two units. Findings:  The physician reviewer found that the enrollee has a medical history of eustachian tube dysfunction, Ehlers-Danlos syndrome, and hypothyroidism. She is also diagnosed with fibromyalgia and temporomandibular joint (TMJ) pain. She currently uses a mouth guard, splint therapy, massage therapy, physical therapy, trigger point injections, acupuncture and cupping to address her TMJ pain. She was seen by an ear, nose and throat (ENT) specialist and saw an oral and maxillofacial surgeon, who recommended onabotulinumtoxina injections, two units, to treat her jaw pain. Most peer-reviewed literature in regard to the use of onabotulinumtoxina injections for TMJ consists of case reports and anecdotal reports on efficacy. There are no randomized controlled studies that report any benefit or any greater benefit than conventional treatments for managing TMJ or myofascial pain. A search of the results for controlled trials comparing botulinum toxin therapy (BTX) (onabotulinumtoxina) versus any alternative intervention or placebo concluded no consensus could be reached on the therapeutic benefit of botulinum toxin therapy on temporomandibular disorders. In light of this, it is not supported that onabotulinumtoxina would be efficacious in managing the enrollees TMJ pain. Final Result: Three of the three reviewers determined the requested treatment is not likely to be more beneficial than any other available standard treatments for the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in oral and maxillofacial surgery 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: Upheld

The patient is a 57-year-old woman with a medical history including chronic asthma and allergies. The patient indicates that in the past she received Serevent metered dose inhaler (MDI), which contains 120 puffs per canister. Her typical dose is two puffs BID (twice a day), which is equal to 120 puffs per months. The manufacturer has converted the MDI into a dry powder inhaler (Serevent diskus inhaler). The diskus formulation dosage is one inhalation BID or 60 per month. The patient wishes to receive 120 doses per month.The submitted progress notes indicate the patient has been on a variety of inhalers including Serevent, Foradil, Flovent and Pulmicort. The patient has requested authorization for an additional Serevent diskus inhaler per month. The Health Plan has denied the patients request on the basis that an additional Serevent diskus inhaler is not medically necessary.Upon review of the submitted records, it appears the patient was previously well-controlled while on Serevent inhaler two puffs BID. When the manufacturer converted the drug to a dry powder inhaler the patient felt that she needed to continue to be on two inhalations BID.The Serevent diskus inhaler does not provide puffs; rather, it is a dry powder inhaler so there is no puff or use of a propellant. The previous version of Serevent was a metered dose inhaler (MDI), which delivered 21 mcg/spray and the recommended dose was two puffs BID or 42 mcg BID. The Serevent diskus inhaler delivers 50 mcg/inhalation, which is at least equivalent to two puffs of the MDI version. Therefore, an additional Serevent diskus inhaler is not medically indicated, as one Serevent diskus inhaler is equivalent to the previous version of Serevent. Furthermore, doubling the dose beyond the Food and Drug Administration recommendation would put the patient at risk for adverse side effects (see SMART research trial).Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old male with low total testosterone and low normal free testosterone levels. Based on this information, the patients primary care physician has recommended testosterone patch or gel replacement treatment to enhance the patients quality of life and to avoid future complications. The Health Plan has determined testosterone replacement therapy is not medically necessary for treatment of the patients medical condition.Testosterone replacement therapy is medically indicated for treatment of documented postpubertal hypogonadism regardless of the cause. Based upon the clinical information provided, there is not clear evidence of hypogonadism. For example, it is not known whether the patient has undergone a genital exam. In addition, no measure of gonadotropin, prolactinomas (PRL), etc. has been provided. Furthermore, it appears the testosterone results are potentially incompatible in that although the patient appears to have significantly low total testosterone, he has a low normal free testosterone, a barely normal free testosterone, and weakly bound testosterone. Sex hormone-binding globulin is also low normal. Thus, the results do not appear to be consistent. Further evaluation and diagnostic workup is needed in order to confirm the patients diagnosis.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should be evaluated by an endocrinologist to confirm if the patient has hypogonadism. If the endocrinologist confirms a diagnosis of hypogonadism, the patients request for testosterone replacement therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an invasive coronary angiography and related services (CPT codes 93458 and 92943). Fathala notes that coronary computed tomography angiography (CCTA) is a perioperative screening tool for detecting patients at high cardiac risk. The American College of Cardiology/American Heart Association guidelines on perioperative cardiovascular evaluation and management do not generally support the use of a coronary angiography in the absence of detectable, significant myocardial ischemia. In this case, given that the patients stress test and clinical findings, including good exercise tolerance and the absence of ischemic symptoms, predicted a low perioperative cardiac risk, and as a CCTA reported that a finding of moderate stenosis was likely overestimated due to the calcification in the segment, the requested service is not medically indicated. Therefore, an invasive coronary angiography and related services (CPT codes 93458 and 92943) are not medically necessary for the treatment of this patient.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: The reviewer is board certified in internal medicine with sub-specialty certification in cardiology 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 patient has requested authorization and coverage for a consultation with an orthopedic surgeon. Current evidence-based peer reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. In this case, the patient has a history of low back pain. She was initially evaluated in the emergency room. She did not report radicular symptoms at that time, and a clinical examination did not document focal neurologic deficits. While a CT scan showed a questionable posterior disc bulge at L5-S1, there were no findings of lumbar scoliosis. The patient reported persistent symptoms. While the provider referred the patient for an orthopedic surgery consultation, the records do not indicate that the patient had failed to improve with conservative treatment or had any red flags warranting an urgent referral. As such, the requested service is not medically indicated for the initial evaluation and management of the patients symptoms. Therefore, a consultation with an orthopedic surgeon is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery 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 47-year-old female patient with a BMI greater than 50 is requesting authorization for the duodenal switch procedure. She outlined a number of comorbid conditions including hypertension, hyperlipidemia, joint pain, back pain, and asthma. The patient has completed a psychological evaluation with a positive recommendation. The Health Plan does not dispute the appropriateness of the patients candidacy for weight loss surgery, but rather the type of surgery the patient should have. The Health Plan has indicated that Roux-en-Y gastric bypass is safe and effective for the surgical treatment of morbid obesity and that the duodenal switch procedure is not medically necessary.The available scientific data does not show an increase in risk, long or short-term, when comparing the biliopancreatic duodenal switch procedure to other surgical weight loss procedures. In fact some of the most common protein deficiencies may be more common in patients who have undergone the Roux-en-Y gastric bypass procedure than those who have had the duodenal switch procedure. Duodenal switch has a far better long-term success rate with regard to sustained weight loss than the gastric bypass operation. These facts are confirmed in the literature provided by the patient. Given the similar safety profile of the two procedures, the superior long-term success of the duodenal switch procedure over gastric bypass supports its medical necessity in this case.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested Protopic 0.1% for the treatment of bullous pemphigoid. Findings:  The physician reviewer found that review of the medical literature regarding the use of Protopic as an adjunct in the treatment of bullous pemphigoid shows that the results are promising. Protopic is at least as safe as topical steroids. Protopic ointment is likely to be of clinical value, and there is no increased risk associated with its use.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Belbuca (buprenorphine HCl buccal film 150 mcg). The records document that this patient has tried and failed several other pain medications multiple other long-acting pain medications including Fentanyl patch, Tramadol ER and Nucynta ER. His provider has requested to switch the opioid tolerant enrollee from Oxycodone to Belbuca in order to provide continuous pain relief with the additional benefit of abuse deterrent properties of the medication. According to the U.S. Department of Health and Human Services, patients who need treatment for pain but not for addiction should be treated within the context of a medical or surgical setting. They should not be transferred to an opioid maintenance treatment program simply because they have become physically dependent on prescribed opioids in the course of medical treatment. This patients provider reports that the treatment goal is to treat the patients pain in a more effective manner with a more favorable risk-to-benefit ratio. The U.S. Food and Drug Administration (FDA) approved indication for Belbuca is for the management of pain severe enough to require daily continuous long-term opioid treatment and for which alternative treatment options are inadequate. The providers notes state that the purpose of prescribing Belbuca is to allow for the safer weaning of oxycodone for post-operative pain control while still affording the patient continuous management of his pain. Furthermore, by using Belbuca, the provider is significantly lowering the patients daily morphine equivalents of 112 morphine milligram equivalents. Based on all information available for review and the current available guidelines, the requested Belbuca (buprenorphine HCl buccal film 150 mcg) to treat the patients chronic pain is medically necessary.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 anesthesiology with subspecialty certification in pain management 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 father of a two-year-old male enrollee has requested for his speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that he is below the age when public education would provide any assistance. It is generally accepted in the medical community that early intervention is optimal for children with developmental delay in language or other areas of development. Speech therapy should be covered for this patient until he is three years of age.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old woman who experienced significant weight loss following gastric bypass surgery.  The patient is status post excision of excess skin on her abdomen, thighs, and arms. She has redundant skin folds at the medial and posterior aspect of the knees. A request has been made for surgical excision of the excess knee skin. The Health Plan has denied authorization for the requested procedure due to lack of documentation of medical necessity.The patient has undergone removal of redundant skin of her abdomen, arms, and thighs. The submitted photographs reveal a modest amount of excess skin about the knees. The submitted records and photographic evidence do not demonstrate that removal of the wrinkled skin in and about the patients knees is medically necessary. There is no evidence of intertrigo or other skin conditions that would warrant surgical excision of the excess skin. Sufficient evidence of a functional impairment has not been provided. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a ten-year-old male enrollee has requested for circumcision for treatment of the enrollees phimosis. Findings:  The physician reviewer found that an adequate course of topical corticosteroid therapy would be most appropriate before subjecting him to a surgical procedure that is not without its own morbidity. Re-evaluation of the request for circumcision would then be appropriate if corticosteroid therapy fails.