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

A forty-eight year-old female with a Chiari malformation is requesting coverage of a referral to a specific institute for Chiari malformation.    Reviewers Findings:  The reviewing physician found that the requested referral is not medically necessary for the patients condition.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. Findings: patients who present with chronic cervical pain, when acupuncture was added to conventional treatment, it relieved pain better and electroacupuncture relieved pain even more. Regarding headaches, acupuncture is an effective and valuable option for patients suffering from migraine or frequent tension-type headaches. The acupuncture notes reported only temporary pain relief. It is unclear whether the patient was instructed in self-care measures (home exercise program, proper biomechanics, etc.). This in order to stimulate self-reliance and avoid dependency on passive care (i.e. acupuncture, massage, etc.). After acupuncture sessions, no specific; measurable; sustained; significant or objective functional improvement in activities of daily living was documented. Therefore, based on the lack of documentation demonstrating medication intake reduction; work restriction reduction; or activities of daily living improvement directly attributable to prior extensive acupuncture; any additional acupuncture is not medically necessary.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 oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his psoriasis. The physician reviewer found that psoriasis typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Otezla has been shown to result in significant improvements in mean percentage change in psoriasis area and severity index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued Otezla treatment. In addition, the U.S. Food and Drug Administration (FDA) has approved Otezla for use in this clinical setting. Given this support, the requested Otezla is medically necessary for treatment of this patients chronic plaque psoriasis. 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria.Findings: A review of the literature suggests that speech and language therapy is successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. The medical literature indicates that individuals who are in the process of transitioning from male to female may often benefit from speech/language pathology services. Speaking fundamental frequency (pitch) and resonance are part of gender transitioning treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender.  However, while speech therapy can be effective in feminizing the voice, in this patients case, there was no information in the records provided about this patients voice to substantiate that the patient is likely to benefit from speech therapy. There was no documentation from speech pathology regarding an evaluation of this patients voice. Therefore, speech therapy is not supported as medically necessary for treatment of this patients medical condition at this time.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 otolaryngology 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

The mother of a four-year-old male with autism has requested authorization for individual doses of the measles, mumps, and rubella vaccines rather than the combination MMR vaccine. She is concerned that the combination MMR vaccine poses a greater risk to children with neurological deficiencies. The Health Plan has denied authorization and coverage for the individual vaccines on the basis that they are not medically necessary.The Health Plans denial should be upheld. There is no scientific evidence that links the MMR vaccine or any vaccine to either the cause or exacerbation of autism. Thus, there is no medical justification for splitting the MMR vaccine in this case. The patient should receive the combination MMR vaccine. Therefore, I have determined the requested vaccine is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested daily doses of Cialis 5 mg tablets for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that the effectiveness of Cialis, Levitra and Viagra are very similar. Results vary from one study to another, but a few have shown better results with Cialis. The medication enhances a receptor by being a PDE-5 inhibitor. A daily dosage allows the patient to take a lower dose and have the receptor inhibitor present on a continual basis. The medication has not been shown to improve symptoms of erectile dysfunction if taken on a daily basis. The medical need for the proposed daily dosage has not been documented in peer reviewed literature. In this case a daily dosage of Cialis 5mg tablets has not been shown to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a nephrologist and/or kidney function test/renal function test (KFT/RFT test). The records provided for review document that this patient has normal baseline renal function and no history of renal disease. In this clinical setting, a nephrology consultation is not indicated. However, for urologic surgery the medical literature and guidelines recommend performance of baseline preoperative kidney function blood tests which typically include, sodium, potassium, chloride, CO2, blood urea nitrogen (BUN), and creatinine. Common complications from surgery include acute renal failure. These baseline preoperative kidney function tests will thoroughly assess the patient prior to considering surgery. Therefore, the requested KFT/RFT test is medically necessary for evaluation of this patient, while the requested consultation with a nephrologist is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partial overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program (IOP) services for treatment of the enrollees major depressive disorder, severe. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). The patient met the criteria for treatment at the intensive outpatient program (IOP) level of care. The records indicate the patient is at serious risk of harm (score 3) with a history of a suicide attempt or gesture by cutting her wrists with a razor. On evaluation, the patient did not have any suicidal ideation, homicidal ideation, psychosis, or hallucinations. The patient demonstrated moderate functional impairment (score 3) and was able to continue to perform well in home school, but has become more isolative and depressed. The patient presents with significant co-morbidity (score 3) with obesity, sinus tachycardia, and major depressive disorder. Although the patient had sinus tachycardia, this did not require intensive monitoring. The patients recovery environment is moderately stressful (score 3) given the serious interpersonal conflicts with her parents. The patients parents are supportive (score 2) but also a source of conflict for the patient. The patient has demonstrated significant response to treatment (score 2) and was described as cooperative with staff and constructive in treatment (score 2). This composite score of 18 is consistent with IOP level of care services. Given these findings, the IOP services were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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: The patient has requested authorization and coverage for Adalimumab (Humira) 40 mg/0.4 mL Pen Injector Kit, quantity 2 every 28 days. According to the American College of Rheumatology (ACR), there is ample evidence to support the use of a tumor necrosis factor inhibitor (TNFi) in patients whose active ankylosing spondylitis has progressed despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The ACR noted that the lack of response or intolerance to at least two different NSAIDs at maximal doses over one month, or incomplete responses to at least two different NSAIDs over two months, supports escalating to treatment with a TNFi agent. In this patients case, email correspondence noted that the patient has tried two NSAIDs. She reports that she has tried naproxen in the past. Additionally, she reported gastrointestinal intolerance with NSAIDs. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested adalimumab (Humira) 40 mg/0.4 mL Pen Injector Kit, quantity 2 every 28 days 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 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the Botox injections billed were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patients diagnoses include face pain, bruxism, myofascial pain, spasm of muscle, and tinnitus. However, the patient does not have a diagnosis supporting an indication for Botox. Specifically, the medical records do not demonstrate that the patient has a neurogenic or musculoskeletal disorder with magnetic resonance imaging (MRI) evidence of nerve root compromise or electromyography findings consistent with a muscle disorder. There is also lack of documentation that the patient has failed to respond to conservative therapy with muscle relaxants, anti-depressants, anticonvulsants and non-steroidal anti-inflammatory drugs (NSAIDs). All told, the Botox injections billed were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Botox injections billed were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Privigen [intravenous immunoglobulin (IVIG)]. In a review paper on the clinical approach to the diagnosis of autoimmune encephalitis in children, Cellucci and colleagues report that behavioral changes, such as repetitive or stereotypical behaviors, irritability, hyperactivity, hypersexuality, insomnia and anger outbursts, are common in pediatric autoimmune encephalitis. Psychiatric symptoms may range from mood swings and mild personality changes to fulminant psychosis and occur in over 50% of autoimmune encephalitis patients. New-onset psychosis in children younger than 13 years of age is uncommon and considered a red flag for an underlying medical, rather than primary psychiatric, condition. The authors further note that the onset of symptoms in autoimmune encephalitis is typically of rapid onset and persist without therapy, in contrast to pediatric acute-onset neuropsychiatric syndrome (PANS) patients, who often experience a relapsing-remitting course. In a cohort study of 21 children with moderate to severe PANS, Melamed evaluated the efficacy of IVIG over a period of six months (six infusions) based on mean changes in psychological evaluation scores using six different assessments, including the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Clinical Global Impression of Severity, and the Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale (PANS Scale). The authors concluded that their results demonstrated statistically significant reductions in symptoms from baseline to end of treatment in all six assessments measured. In this case, the records note that the patient had an abrupt onset of severe psychiatric symptoms. She responded poorly to previous therapies, including multiple psychotropic medications, antibiotics, steroids and non-steroidal medication. She underwent an appropriate diagnostic workup, including a normal brain MRI and 24-hour EEG. The records noted positive titers for mycoplasma and pneumococcus. The patient reported some improvement in her psychiatric symptoms following two infusions of IVIG, which were separated by over a year, an atypical regimen for administration. Given the refractory nature of this patients course, and previous documented response to IVIG, the requested services are medically indicated. Therefore, Privigen (IVIG) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 neurology with special qualification in child neurology 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 62-year-old female is requesting Restor lenses for treatment of her glaucoma.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient has a history of diabetes and previous Lasik treatment. She was found to have decreased visual acuity and cataracts on examination. The provider recommended cataract surgery with Restor lens implant and this was done. The use of multifocal intraocular lens implant (IOL) in her treatment was not medically necessary even considering her history of previous Lasik surgery. The relevant medical literature, including the references cited above, suggest that cataract surgery using a standard (monofocal) IOL is likely to result in equivalent outcomes when compared to multifocal IOL devices. Further, the purpose of implanting the Restor IOL was apparently attempted to provide the patient with less dependence on glasses after the cataract surgery. However, the additional benefits of Restor IOL are for the patients convenience and are not medically necessary to improve the outcome of the procedure. For this reason, the Health Plans characterization of the cataract surgery with Restor IOL placement as cosmetic is appropriate and the scientific data does not suggest that Restor IOL is necessary for management of her condition due to her history of Lasik.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested continued IV potassium for home use and the use of home health services for the treatment of her hypokalemia. Findings:  The physician reviewer found that this patient has been diagnosed with chronic hypokalemia, most likely aggravated by use of loop diuretics and inadequate fluid restriction. Under the controlled setting of acute inpatient care, the condition is adequately treated by relatively low dosages of enteral potassium and fluid restriction. What seems to cause the hyperkalemic episodes is the constant use of loop diuretics for the purpose of peripheral edema. The literature states that one of the more common causes of potassium deficit is diuretic therapy. In the case of this patient, secondary causes of hypokalemia were explored and excluded as causal factors to explain the hypokalemia. Treatment is aimed at replacing potassium loss and preventing further loss. The appropriate replacement is either oral or intravenous. Preventing further loss can be accomplished by ceasing the use of loop diuretics in this patients case. The potassium-sparing diuretic, Aldactone, was used effectively in this patient. Based on review of the medical literature, intravenous potassium supplementation should only be administered for severe cases of hypokalemia and typically is performed in the inpatient setting to allow for telemetry monitoring, given the potential cardiac effects of potassium. Standard of care does not dictate intravenous potassium supplementation for chronic hypokalemia as the risks outweigh the benefits, especially in this particular patient. Rothschild and colleagues found that potassium supplements were one of the classes of medication that were associated with adverse drug reactions that may lead to serious injury. Given this evidence, use of intravenous potassium in a home setting is not consistent with standard of care, especially in light of the risks potentially involved with cardiac arrhythmias. For this particular patient, it has been demonstrated that stable serum potassium levels could be achieved though use of oral supplementation, fluid restriction and discontinuation of loop diuretics. Continued IV potassium for home use and the use of home health services for this treatment are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Xenical 120 mg three times daily for treatment of his obesity and hypertension.  Findings:  The physician reviewer found that the patient has complications of his obesity including hypertension treated with emergency department visits, and has made previous efforts to lose weight. Moreover, the patients provider noted recent increased BMI of 38, which meets the criteria for treatment with the requested weight loss agent. Thus, the requested Xenical 120 mg three times per day is supported as medically necessary for treatment of this patients medical condition.