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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: The parent of the enrollee has requested reimbursement for partial hospitalization program services and prospective authorization and coverage for future partial hospitalization program services specializing in children with autism. This patient completed approximately six weeks of partial hospitalization program treatment. He has a confirmed diagnosis of autism and has been referred for ABA services. Progress notes from the partial hospitalization program indicate that the patient continued to have some potential aggression issues. The progress notes indicate that ABA therapy on an outpatient basis was recommended and was occurring. The progress notes do not indicate clinical reasons as to why partial hospital program would be necessary to treat the patient versus ABA therapy, which is routinely administered on an outpatient basis. The patient did not have active medical issues that were affecting his treatment. His family is actively engaged in treatment. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. The patient has a composite score of 15. This score correlates with intensive outpatient services. Therefore, partial hospitalization program services and future partial hospitalization program services specializing in children with autism were not and are not medically necessary for the treatment of 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 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

A male enrollee requested the Barnett continent intestinal reservoir for medical treatment of his malfunctioning ileostomy with stomal prolapse. Findings: The physician reviewer found that this patient has chronic problems with stoma dysfunction, colonic dysmotility, and pelvic floor dysfunction. Although a continent ileostomy is not a routine surgical intervention, it has been shown to be highly effective in appropriately selected patients. The evidence supports the procedure in this clinical scenario given this patients stoma dysfunction following exhaustion of all other reasonable means of therapy. All told, the requested Barnett pouch is medically reasonable and necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees headaches. Findings:  Two physician reviewers found that the patient has chronic neck pain, cervical disc disease, and chronic daily headaches.  In the past, the patient has tried Indocin, Vicodin, Imitrex, and Cymbalta for his headaches.  He has requested coverage for Botox injections.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  This denial is the subject of this appeal.  Botox injections are not indicated for cervical neck pain.  Although there is some literature supporting its use for migraine headache, it should not be selected over more studied headache prophylaxis medications.  In this particular case, the submitted documentation does not demonstrate that the patient has been tried on the traditional migraine/headache preventative medications (such as beta blockers, calcium channel blockers, Elavil, and Topamax), nor is there a documented contraindication to these medications.  The requested Botox injections are not likely to be more beneficial than these proven therapies.  All told, the requested Botox injections are not likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. This patient presents with atopic dermatitis with involvement of over 20% of his BSA. The patient has failed treatment with oral prednisone 20 mg, Keflex 500 mg, and clobetasol. His provider has recommended treatment with Dupixent. The treatment of atopic dermatitis initially involves the use of nonpharmacologic interventions like emollients. The next step in treatment includes topical interventions, such as topical corticosteroids. For patients with widespread disease not controlled by topical agents, systemic treatment is appropriate. Dupixent is a U.S. Food and Drug Administration (FDA) approved medication that is safe and effective for the treatment of atopic dermatitis (Gooderham, et al.; Eichenfield, et al.). Dupixent has an excellent safety and effectiveness profile, and its use is considered standard of care in the treatment of atopic dermatitis. Given this support, the requested Dupixent 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested multiple outpatient therapy sessions for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates measurable improvement in the patients condition since she was admitted to inpatient treatment. The psychiatrists progress notes point to a steady improvement in the patients mood, perspective, and willingness to engage in treatment. Thereafter, all of the submitted documentation points to a similarly improved state, further supported by therapists notes, which regularly cite attended session, she appeared happy and emotional. Given the distinct absence of any significant symptoms by the point of the patients discharge from residential treatment, there is no documentation to support the need for the requested therapy sessions.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 50-year-old male with a long-standing history of degenerative disc disease of the mid and lower lumbar spine. The patient has requested an MRI of the lumbar spine to determine if he is a suitable candidate for artificial disc replacement. The patient takes hydrocodone for pain, but there is no record of conservative therapy such as physical therapy or NSAIDs. There is no evidence of a recent visit to a spine specialist (i.e., neurosurgeon or orthopedist) or the neurological symptoms or findings associated with his chronic back pain. The plain films of the lumbar spine submitted for review are from 1994 and 2001.  The patients request for authorization of an MRI of the lumbar spine was denied by the Health Plan, citing a lack of medical necessity.There is no documentation suggesting the patient has been recently evaluated by a spine specialist, or documentation of neurological symptoms/findings or recent physical therapy. MR imaging of the lumbar spine is medically appropriate when a patient has severe back pain that does not improve with conservative therapies, has significant neurological symptoms/findings (i.e. foot drop) or when a patient is being considered for surgery and has recently been seen by a surgeon. The patient does not meet any of these criteria at this time and therefore MR imaging of the lumbar spine is not medically appropriate. Therefore, I have determined the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan (generic name rifaximin) for the treatment of irritable bowel syndrome with diarrhea (IBS-D). Gatta and Scarpignato note that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Morariu and colleagues found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of IBS by possibly counteracting SIBO. In this case, the records show that the patient has SIBO, confirmed on a breath test, and IBS-D. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve the symptoms of irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablet 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 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 26-year-old male enrollee has requested The Vest Airway Clearance System (Vest) for the treatment of his bronchiectasis. Findings:  Three physician reviewers found that the nationally accepted medical necessity criteria for high frequency chest wall oscillation devices (HFCWO) such as the Vest system indicates such equipment is necessary for patients who have a diagnosis of bronchiectasis and have failed available standard treatments. This patient has a diagnosis of bronchiectasis and has failed available standard treatments. The Vest system is medically indicated for this patient and is likely to provide significant benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a nephrologist. The records provided for review document a recurrent problem of unclear etiology involving the genitourinary system. The patient is noted to have UTIs as well as hematuria. She is noted to take non-steroidal anti-inflammatory drugs (NSAIDs). A nephrologist is most familiar with several conditions including papillary necrosis related to ibuprofen intake, medullary sponge kidney, and loin pain hematuria syndrome. Further, issues such as neurogenic bladder related to comorbid conditions should be ruled out. The nephrologist has a role in the diagnosis of recurrent UTIs. 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 internal medicine with subspecialty certification in nephrology 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 gene testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The high-risk criteria for this test include a maternal age greater than or equal to 35 years of age, history of previous pregnancy with fetal trisomy, presence of sonographic findings associated with fetal aneuploidy, parental balanced robertsonian translocation with increased risk of trisomy 21 or 13, and screen-positive result for aneuploidy on screening tests.  In this case, the patient had none of these risk factors.  Therefore, gene was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in obstetrics and gynecology 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: A 21-year-old male enrollee has requested authorization and coverage for EXONDYS 51 (eteplirsen). The submitted documentation supports the medical necessity of the requested medication. Based on the review of the medical data presented in this clinical setting, the requested medication, EXODYNUS 51, is medically appropriate and indicated for the treatment of Duchennes muscular dystrophy for this patient. The provider presents supporting evidence that the patient has demonstrated a measurable clinical benefit since participating in the EXONDYS 51 (eteplirsen) clinical trial as evidenced by a higher preservation of pulmonary function vital capacity and upper limb strength compared to historical data of those with Duchenne's muscular dystrophy not taking EXONDYS 51 (eteplirsen). 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested occupational therapy (OT) for treatment of the enrollees autism. Findings:  The physician reviewer found that OT addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development. Based upon the documentation provided, this 10-year-old patient should receive an OT evaluation through an independent provider not affiliated with the Health Plan to assess his current level of function. Given the absence of this documentation, it is unclear whether the patient requires OT therapy at this time. The results of the independent OT report should assist in determining the medical necessity of the requested OT services and the independent OT evaluation should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant 360 Test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that there is support for the services at issue in this patients case. The National Comprehensive Cancer Network guidelines for non-small cell lung cancer strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients. In this clinical setting, Guardant 360 Test is considered a standard of care. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether vertebral axial decompression provided was likely to have been more beneficial for treatment of the patients condition than any available standard therapy. The patient complained of ongoing pain in the neck and low back. The physical examination revealed decreased and painful range of motion in the cervical and lumbar spines. There was tenderness with palpation and muscle spasms noted in multiple areas.Findings:  Two out of three physician reviewers found that the medical literature shows that traction/decompression is not more effective than other standard therapies. Studies indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias.Final Result: The reviewers determined that the requested treatment was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in chiropractic care and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Humatrope cartridge kit 24 mg-1.8 mg daily. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a Humatrope cartridge kit 24 mg-1.8 mg daily is medically necessary for the treatment of the patients medical condition. The Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee reported the guidelines for the use of growth hormone in children indicate that considerable variability exists in the diagnosis of GH deficiency, which remains a clinical challenge. This is related to the continuum between severe GH deficiency and normality, marked variability in GH assays, arbitrary cutoffs conventionally used to define GH deficiency on the basis of GH stimulation tests, and the lack of reproducibility of GH stimulation tests. In addition, the patients physical examination indicates that he is already in the midst of his pubertal growth spurt, suggesting less benefit from recombinant GH. The medical evidence does not support the requested medication in this clinical setting. Therefore, a Humatrope cartridge kit 24 mg-1.8 mg daily 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 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

A 45-year-old female enrollee has requested authorization and coverage for Provigil for treatment of her hypersomnolence.  Findings:  The physician reviewer found that this patient has hypersomnolence that interferes with her activities of daily living and her quality of life. Some consideration should be given to the patients regular nightly use of Valium as it may contribute to her excessive daytime sleepiness; the newer sleep agents are less likely to produce this effect. Nonetheless, Provigil was prescribed over one year ago and there has been a very good subjective response. Within the neurological community, idiopathic hypersomnolence is commonly treated with Provigil.