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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a sleep study with continuous positive airway pressure. The  American Academy of Sleep Medicine (AASM) clinical practice guidelines for the treatment of adult OSA with positive airway pressure (PAP), recommend that PAP therapy be initiated using either automatic PAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. The guidelines note, The choice of PAP initiation in the home or lab should be based on access, cost-effectiveness, patient preference, sleep clinician judgement, and other factors. In this case, the patient was diagnosed with mild OSA and did not have significant comorbidities. Her provider recommended an in-laboratory CPAP titration study. There is sufficient support for the service at issue in this clinical setting. Therefore, the sleep study with continuous positive airway pressure was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was 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 otolaryngology with sleep-study certification in sleep 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Spinraza medication therapy. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees spinal muscular atrophy, type 2.Findings:  Currently, Spinraza (nusinersen) is the only U.S. Food and Drug Administration (FDA) approved therapy for the treatment of SMA. In addition, the medication nusinersen has been shown in clinical studies to be effective for SMA of all types. Medical literature shows Nusinersen was found to be safe and well tolerated across all age groups studied. Nusinersen has irrevocably altered the natural history of SMA and allowed for the first time children to transition between SMA types. Nusinersen should be considered as standard of care for the treatment of SMA of all types. Per the FDA approval, Spinraza is indicated for the treatment of SMA in pediatric and adult patients. In addition, there is a lack of available therapies for treatment of SMA. The natural history of the disorder is progressive weakness which progresses to respiratory failure. Spinraza, which has FDA approval, has been shown to alter the disease progression. In sum, Spinraza injection treatment has been demonstrated as likely to be more effective for treatment of the patients SMA, type 2, than any available standard treatment options.Final Result: Two of the three reviewers determined that requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Evekeo tablets. Findings:  The physician reviewer found that the submitted documentation supports that the requested medication is medically necessary. The literature on stimulant medications in children indicates that appetite suppression can be a symptom that requires discontinuation of the medication. The literature indicates that trials of stimulant medications of different classes or different preparation such as long-acting or immediate release may impact side effects. A trial of different medications with different chemical compositions or delivery mechanisms can be effective for treatment of attention deficit hyperactivity disorder symptoms while reducing intolerable side effects. In this case, the patient has had trials of other medications that have caused significant side effects and warranted discontinuation of the medication trials. The medical providers decision to try different medications in hopes of reducing appetite suppression and other adverse effects of prior medication trials was prudent and supported by the literature. The requested medication, Evekeo, is U.S. Food and Drug Administration (FDA) approved for the patients condition and has shown to be successful for the patient with few side effects. Under these circumstances, Evekeo is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuvigil (armodafinil). The submitted documentation fails to demonstrate the medical necessity of the medication at issue. In this case, the patient reported that she has been diagnosed with narcolepsy and idiopathic hypersomnia.  Both of these diagnoses require that there be a combination of objective findings on sleep testing and exclusion of other causes of hypersomnolence undertaken by history. In this case, the patients polysomnography was negative for both narcolepsy and idiopathic hypersomnia, based on the mean sleep latency being greater than eight minutes and an absence of sleep onset rapid eye movement periods. Thus, the reported diagnoses of narcolepsy and idiopathic hypersomnia are not supported by current diagnostic standards. There is a lack of support for the medication at issue in this clinical setting. Therefore, Nuvigil (armodafinil) was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 neurology with sub-specialty certification in sleep 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:   The parent of an enrollee has requested trauma services (CPT code 0681) for treatment of the enrollees medical condition.  The physician reviewer found that based upon the information provided for the review as well as the available evidence-based criteria, activation of the trauma team was medically necessary in this clinical setting. According to the Centers for Disease Control and Prevention (CDC) guidelines for field triage of injured patients, when evidence of a high energy impact exists, patients should be transported to a trauma center. CDC guidelines also note that evidence of such a high energy impact would include auto versus pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact. The mechanism of injury in this case justifies transport to a trauma center and trauma center activation because of the significant nature of the mechanism of injury. Further, the patient was appropriately triaged due to a concerning mechanism of injury. Moreover, the Pediatric Trauma Society guidelines for pediatric trauma team response state that a child can be called as a trauma stat at the discretion of the Emergency Medicine physician or Trauma Surgeon. As such, the trauma services (CPT code 0681) were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 pediatrics and pediatric critical care 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 patient is a 48-year-old male who experienced neck, left shoulder, left wrist and upper back pain following a motor vehicle accident. He also has a history of right shoulder pain. The patient believes his physical therapy regimen was prematurely discontinued in May 2006. He has requested authorization and coverage for additional physical therapy visits. The Health Plan has denied his request indicating the requested therapy is not likely to be beneficial and therefore is not medically necessary. The submitted physical therapy notes do not document any long-term functional improvement with the patients past therapy. Nor does it appear the patient achieved the goals set at the beginning of therapy. In addition, the patient was instructed in a home program and should be able to continue exercising at home. Additional physical therapy is not likely to result in an improved clinical outcome. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested for sclerotherapy for treatment of her lower extremity varicosities.  Findings:  Two physician reviewers found that the saphenous veins were not removed, and she now has symptoms related to the remaining saphenous veins and varicosities. Given the presence of bilateral reflux, it is reasonable to treat the residual saphenous veins and branches.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old female with leg pain.  She was referred to a vascular surgeon, who performed photoplethysmography and concluded that she needed high ligation and stripping of the left saphenous vein. There is no mention that compression stockings were used or that other studies, like venous duplex, were performed. The record does not provide much detail as to clinical symptoms or physical exam findings. The patient has requested authorization for the recommended procedure.  The Health Plan has denied this request based upon a determination that saphenous vein stripping is not medically necessary.Photoplethysmography is a rudimentary method, which uses a transducer that emits infrared light into the dermis. The back-scattered light is measured by a photodetector and displayed as a line tracing.  This is not a very accurate way of measuring the presence or absence of venous insufficiency.  The results have not been standardized and it is very hard to quantify the readings. This procedure is not particularly helpful in evaluation of the problem or making a determination as to the most appropriate intervention.  At this time, neither the patients symptoms nor her varicies have been adequately evaluated.The recommendation to return to the primary care provider for a trial of conservative therapy is a reasonable one.  If symptoms persist the patient should be re-referred to a vascular surgeon for a venous duplex study.  Todays technology offers more accurate and sophisticated diagnostic methodology than photoplethysmography provides. The standard of care requires a venous duplex study for evaluation of greater saphenous vein (GSV) insufficiency and assessment of the deep veins before proceeding with any type of invasive surgical intervention.  Based upon the information set forth above, I have determined 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

Nature of Statutory Criteria/ Case Summary: This is a patient with a diagnosis of glioblastoma. The patient had treatment with a surgical resection of the tumor, surgery with gamma knife, radiation, and chemotherapy. The patient showed progression of the disease after being on a clinical trial. The provider is requesting Keytruda medication. At issue is whether the Keytruda (pembrolizumab) is medically necessary to treat the patients medical condition. At this time, there is insufficient clinical literature support for the use of Keytruda for the diagnosis of glioblastoma. Researchers reported an observational study for the use of pembrolizumab in recurrent high-grade glioma, which showed that in those patients with glioblastoma, all reported progressive disease with the use of Keytruda. Another finding reported a clinical trial of pembrolizumab in recurrent glioblastoma with the conclusion that there is insufficient response and the majority of glioblastoma patients. The current National Comprehensive Cancer Network Guidelines (2020) does not list pembrolizumab as a recommended treatment option for glioblastoma.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Ferriprox. The enrollee has sickle cell disease, and hemochromatosis due to repeated blood transfusions and transfusion iron overload. Other diagnoses include chronic kidney disease, stage 3b-4, and hypertension. His physician is requesting Ferriprox to treat iron overload. There is considerable experience with iron chelation therapy in hemoglobinopathies where organ and total body iron has been shown to prevent organ iron deposition and dysfunction. Hereditary sickle cell disease is a hemoglobinopathy. Phlebotomy to reduce iron overload cannot be done in sickle cell disease due to anemia, so iron chelation therapy is needed and has proven beneficial.  Deferiprone (Ferriprox) is a more recent approved chelation therapy for iron overload in enrollees with hemoglobinopathies.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested facial feminization treatment of the enrollees gender dysphoria. Based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary and are not reconstructive in nature. The medical literature supports facial feminization surgeries which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. However, in this patients case the submitted documentation does not support a typical functional deficit for each of the requested services. A formal examination was not documented. In addition, based on the submitted photographs, the patient has minimal forehead prominence, mildly prominent brows and mild ptosis which could be consistent with a relatively normal female appearance.  The appearance of the patients forehead and brow is not necessarily gender specific. Further, details regarding the patients lower face, chin, and nose are not documented in the records provided. Based on the submitted photographs, the patients lower face, chin and nose appears consistent with a relatively normal appearance and not specifically gender related. Thus, the patients current appearance falls within the spectrum of typical female appearance.  With regard to whether the requested services are considered reconstructive in nature, there is a wide spectrum of facial appearance that can be consistent with typical female appearances. In this patients case, the facial features she is seeking are consistent with a female appearance and are not considered abnormal. The requested services appear consistent with aesthetic improvement, addressing appearance concerns and are not specific to sex-related abnormalities. Thus, the requested services would be considered cosmetic enhancements and are not required to address an abnormal structure.Findings:The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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

A female enrollee requested substance abuse residential treatment center (RTC) services  for medical treatment of her substance abuse.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented for detoxification after her provider refused to refill her prescription medication. The amount of medication she was using did not require inpatient detoxification. In addition, her withdrawal symptoms did not result in a COWS score to support a residential level of care. Her psychiatric and medical conditions were managed with medications and did not require 24-hour supervision. She had no prior treatment history and there is no evidence to suggest that treatment at a lower level of care would have resulted in complications or that she was at imminent risk for withdrawals. Based on the medical literature cited above and the documentation submitted for review, the substance abuse residential treatment center services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test. The records provided for review document the presence of dysphagia and odynophagia. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted as an initial test for evaluation of patients with dysphagia. In patients with dysphagia, there is concern for eosinophilic esophagitis, and endoscopic biopsy is currently the only method for diagnosis. In addition, this patients odynophagia could be due to etiologies such as candidiasis, esophagitis, and ulceration, most accurately diagnosed by endoscopy. Therefore, the requested endoscopy with biopsies is medically necessary for the evaluation of this patients dysphagia and odynophagia. In addition, the documentation states that colonoscopy is planned if testing for Clostridium difficile is negative. The most recent ASGE guidelines state that colonoscopy with biopsies is warranted for evaluation of diarrhea, and colonoscopy with biopsy is useful for diagnosis of microscopic colitis and other causes of diarrhea. Accordingly, the requested colonoscopy with biopsies is medically necessary for the evaluation of this patients diarrhea.Esophageal manometry is also supported for the evaluation of longstanding dysphagia. This patient may have a functional or esophageal dysmotility disorder as a cause for her dysphagia, even if a structural esophageal disorder is found on endoscopy. Thus, the requested esophageal manometry test is medically necessary for the evaluation of this patients dysphagia. All told, the requested endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test are medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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

A 62-year-old male enrollee has requested for a return to a acute rehabilitation facility for an additional two weeks of treatment for treatment of his medical condition.  Findings:  The physician reviewer found that there is no significant change that would be expected from further inpatient rehabilitation that would alter his home care needs. Although he initially declined upon transfer home, once therapy was initiated he progressed. The patient is able to make further gains at home.