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

The patient is a 20-year-old man with a two-year history of low back pain. The patient has undergone conservative treatment yet his symptoms persist. He has not received epidural injections. The patient appears to have congenital spondylolisthesis. It has been recommended he undergo surgery in the form of spinal fusion. The Health Plan has denied authorization for lumbar spine surgery on the basis that it is not medically necessary for treatment of the patients back pain.In light of the patients persistent pain the treatment of choice is surgery. Though the patient has not yet undergone epidural injections, such treatment is not definitive and at the most would provide only temporary relief. For definitive treatment of the patients condition a spinal fusion is medically appropriate and indicated. Given the failure of conservative treatment it is not likely that continuation of conservative measures will alleviate his pain. Therefore, I have determined that 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested orchiectomy and vaginoplasty/labiaplasty for treatment of the enrollees gender dysphoria. Bilateral orchiectomies and vaginoplasty/labiaplasty are part of the surgical transition process for male to female transition. Based on the medical records provided, this patient has well-documented gender dysphoria. She has previously undergone parts of gender transition with apparent success. She has been undergoing hormonal therapy and has been living as a female. Furthermore, the medical literature recommends that after a diagnosis of gender identity disorder, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. In this patients case, the recommended criteria have been established. For treatment of her gender dysphoria, her external anatomy should be more consistent with a female anatomy than of a male. Bilateral orchiectomy and vaginoplasty/labiaplasty are consistent with the appropriate female anatomy. The Health Plan had indicated that this patient was not compliant with treatment regimens, office visits and necessary laboratory tests. However, the submitted documentation supports that this patient has addressed these issues and her most recent office visits and therapy sessions appear consistent with the Health Plans clinical criteria. As such, the medical documentation supports the requested services in this patients case.Findings:The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:The reviewer is board certified in plastic 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica. Findings:  The physician reviewer found that in the documentation available for review, not all treatment options have been exhausted. Specifically, behavior therapy has not been discussed or completed despite much research to support its use. In addition, the non-controlled medication gabapentin has not been optimized and the dose of gabapentin that failed to provide adequate pain relief was not documented. Moreover, the Lyrica is noted to cause headaches for this patient and no objective functional improvement is documented. For these reasons, the requested Lyrica is not medically necessary for treatment of 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 anesthesiology 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the chemotherapy medication cabazitaxel.The submitted documentation supports that the requested medication is medically necessary. Chemotherapy is certainly appropriate in prostate cancer patients who have become refractory to hormonal therapies. The most commonly used drug is taxotere. In this case, however, the patient has an unusual autonomic nerve dysfunction, aphonia. Accordingly, his doctor is concerned with possible neurotoxicity from the taxotere. Cabazitaxel is a taxane drug, similar to taxotere, with equivalent efficacy to taxotere, but with less potential for neurotoxicity. Cabazitaxel is generally used once taxotere fails, but it is a reasonable first choice in this particular patient, because of the concern for neurotoxicity. Accordingly, under these circumstances, the requested medication, cabazitaxel, 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 internal medicine, with subspecialty certification in medical oncology, 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

An enrollee has requested authorization and coverage of Mavyret 100 mg - 40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to the 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 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-2 trial showed a 99% cure rate with eight weeks of treatment AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 - 40 mg tablets for eight weeks for treatment of hepatitis C is supported as 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 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: Overturned

A 34-year-old male enrollee requested one-to-one weekly therapy for medical treatment of his adjustment disorder with depressed mood.   Findings:  The physician reviewer found that this patient has panic disorder as well as likely generalized anxiety and possible major depressive disorder.  Weekly psychotherapy is known to be effective for treatment of this patients conditions. Leichsenring and Rabung provided evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions are associated with better outcome. Given this patients symptoms and his providers recommendation to continue psychotherapy on a weekly basis, the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old male enrollee has requested authorization and coverage for a magnetic resonance (MR) spectroscopy for evaluation of his Addisons disease and adrenoleukodystrophy (ALD).  Findings:  The physician reviewer found that Adrenoleukodystrophy (ALD) is a rare neurodegenerative metabolic disorder, which is X-linked and leads to quadriparesis, blindness, dementia and death. Lorenzos Oil has been shown to slow the progression of ALD in those patients who are asymptomatic.MR spectroscopy has demonstrated excellent efficacy in monitoring the progression of ALD, and is routinely used at the ALD Centers of Excellence. By monitoring MR spectroscopy, the patients response to therapy with Lorenzos Oil can be assessed in order to avoid bone marrow transplantation, which is the only effective treatment once neurologic symptoms have started. MR spectroscopy is clinically indicated for this patient and should be approved on a yearly basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (generic form apremilast) 30 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. 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 biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has severe plaque psoriasis affecting more than 20 percent of their BSA that requires systemic treatment. The anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, the requested Otezla tablets are medically necessary for the 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

The parent of a two-year-old male enrollee has requested speech therapy services at a frequency of two times per week for treatment of the enrollees severe receptive language impairment and severe expressive language impairment.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has severe speech and language delay in both receptive language and language expression. His delays may be due in part to his prematurity and eustachian tube dysfunction, or may have arisen independent of these issues.  His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested speech therapy services at a frequency of two times per week are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested brachytherapy for treatment of her basal cell carcinoma on the face.  The physician reviewer found that basal cell carcinoma is the most common form of non-melanoma skin cancers in the Caucasian population representing approximately 75%. The standard of care for basal cell carcinoma is typically local destruction or surgical removal, including electrodessication and curettage, elliptical excision, or Mohs micrographic surgery. In selected patients, radiation, including external beam radiation or brachytherapy, is an appropriate and effective option. With the advent of precise surgical treatments, such as Mohs micrographic surgery, which offers tissue-sparing tumor removal, the use of radiation for basal cell carcinoma has declined. There are significant limitations in the use of brachytherapy for treatment of basal cell carcinoma. Specifically, the tumors that respond best with the lowest recurrence rates are primary, superficial less than 2 mm deep, and small less than 2 cm in diameter. Most studies have found that adequate radiation dosage with brachytherapy cannot be delivered at depths much greater than 2 mm, making the treatment of infiltrative tumors impractical. All told, the requested brachytherapy is not medically necessary for treatment of this patients basal cell carcinoma. 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 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

A 44-year-old female enrollee has requested for neuropsychological testing for evaluation of her memory loss.  Findings:  The physician reviewer found that the available peer reviewed medical literature and the medical records, this patient does not meet generally accepted indications for neuropsychological testing. Neuropsychological consultation is appropriate for persons with cognitive, behavioral, or emotional difficulties that are suspected to involve trauma, disease, or aging, and which have a negative affect on a persons way of functioning. Indications include the following: acquired brain injury or progressive degenerative disease (i.e., Alzheimers disease, Parkinsons disease, Huntingtons chorea, and multiple sclerosis); psychiatric conditions with a high index of risk for neurological (organic) involvement (i.e., chronic alcoholism, schizophrenia); attention, memory, or language problems that affect daily functioning, but for which the causes are unclear, unknown, or poorly delineated (i.e., adult ADHD); and identifying and measuring cognitive abilities of persons who are preparing to undergo a neurosurgical procedure, and re-testing of the person after the surgery. The clinical evidence does not support neuropsychological testing for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. 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

The parent of a nine-year-old male enrollee requested vancomycin HCL (Vancocin) 250 mg for medical treatment of the enrollees primary sclerosing cholangitis. Findings:  Three physician reviewers found that this patient has had demonstrated improvement in his liver histology and hepatic function tests after receiving therapy with vancomycin.  There is sufficient anecdotal evidence to support the use of Vancocin 250 mg in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested authorization and coverage for Echocardiography, transthoracic, real-time with image documentation (2D), including M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography. The enrollee has also requested authorization and coverage for Holter monitoring/reporting for up to 48 hours for evaluation of the enrollees chest pain.  Findings:  The physician reviewer found that based on the records provided the patient is a 57-year-old female with a history of known coronary disease who presents with symptoms interpreted by her physician as palpitations but no documentation of chest discomfort, dyspnea, or abnormal cardiovascular physical exam. An electrocardiogram on was normal on review. In this circumstance of unexplained palpitations in a patient with known coronary disease and prior myocardial infarction, further evaluation with Holter monitoring is reasonable, appropriate, and considered standard accepted practice in the medical community. The American College of Cardiology (ACC) and American Heart Association (AHA) expert consensus guidelines consider unexplained palpitations a class I indication for Holter monitoring. However, there is record of a prior echocardiogram about one year ago and no current cardiac symptoms or abnormal cardiac physical exam findings that would warrant a repeat echocardiogram. The current expert consensus guidelines also do not consider repeat echocardiography appropriate in this setting. For these reasons, the requested Holter monitoring is medically necessary while the requested echocardiography is not medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sleeve gastrectomy. According to the American Society for Metabolic and Bariatric Surgery, qualifications for bariatric surgery in most areas include a BMI greater or equal to 40, or more than 100 pounds overweight; a BMI greater or equal to 35, with at least one or more obesity-related co-morbidities such as type II diabetes, hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease; or an inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.In this case, the patient meets all nationally accepted criteria for bariatric surgery, including those published by the American Society for Metabolic and Bariatric Surgery. The patient is an adult with a BMI that is greater than 35 kg/m2, with morbid obesity and the presence of an obesity-related co-morbid condition, sleep apnea. The patient has failed dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. Therefore, the requested sleeve gastrectomy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested procedure 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 general 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.