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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine-tetracaine and Vaniqa.Hirsutism has been linked to PCOS and can present in varying clinical degrees for patients. Hirsutism has varying degrees of impact, and treatment options need to be individualized. Vaniqa (eflornithine) is a topical option for the treatment of hirsutism in women. Eflornithine cream can reduce hair growth by irreversible inhibition of ornithine decarboxylase, an enzyme important for normal hair growth. It is approved by the U.S. Food and Drug Administration (FDA) for the removal of facial hair in women. Clinical trials have found that combining eflornithine with laser hair removal results in a more rapid response than laser treatment alone. Electrolysis can be painful, and topical anesthetic creams such as EMLA or LMX (lidocaine cream) may be helpful in reducing pain when electrolysis is performed in sensitive areas.In this case, the patient suffers from severe hirsutism that requires daily care for facial hair growth. The patient also has documented depression, anxiety and suicidal ideation as a result of her hirsutism. The patient's severe hirsutism has significantly impacted her quality of life in both her mental and physical health. Records reflect that the patients degree of symptoms and impact are quite significant, and treatment should not be considered as purely cosmetic. The patient has tried alternative treatments with no significant improvement in symptoms, and she would now like to proceed with Vaniqa and electrolysis. Under these circumstances, lidocaine-tetracaine and Vaniqa are medically necessary to treat the patients mental health condition.Final Result: The reviewer determined that the requested medications are medically necessary to treat the patients mental health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 patient is a 37-year-old female with dysfunctional dental malocclusion. Her condition has been evaluated and the diagnosis confirmed by her oral surgeon and an orthodontist. The patient has a history of bruxism and headaches related to mandibular retrognathia and class II, over compensated dental malocclusion. The patients provider submitted a request for authorization of sagital split osteotomy (CPT Code 21196) and advancement genioplasty (CPT Code 21121). The Health Plan denied the request based upon a determination that the procedures are not medically necessary.The patient has a common condition which produces physical discomfort. The proposed treatment includes bilateral mandibular osteotomies to advance and reshape the mandible in order to provide a fully functional dental occlusion. Pre-surgical orthodontic treatment is usually required as it is in this instance. The goal of the surgery is the elimination of chronic pain by providing a balanced dental occlusion.  After reviewing the cephalometric analysis it does not appear there would be much, if any, cosmetic effect from the surgery (bilateral osteotomies). There would be a significant negative cosmetic effect if treatment of the malocclusion was attempted by dental extractions and orthodontia alone. It appears from the record the patient has good lip competence, so advancement genioplasty and submandibular liposuction are not part of the functional correction and are considered cosmetic procedures.In summary, correction of the mandibular retrognathia with bilateral mandibular ramus osteotomies (CPT Code 21196) will provide a fully functional dental occlusion and is medically indicated for treatment of the patients chronic pain. This procedure will likely result is significant functional improvement. However, advancement genioplasty and submental lipectomy would be primarily for cosmetic improvement, and would not be medically indicated. Therefore, I have determined that one of the requested procedures is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Prometheus Anser ADA serum assay. Findings:  Three physician reviewers found the Prometheus Anser ADA serum assay was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. The Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in response failures. However, there are few well-controlled clinical trials to confirm the utility of the Anser testing in this clinical leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. This patient presents with recent symptoms intermittent pain and diarrhea. However, there is a lack of elevation in his inflammatory markers known to correlate with a Crohns flare. For these reasons, the Prometheus Anser ADA serum assay was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for biofeedback therapy Findings:  Two of the three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Neurofeedback is a specific form of biofeedback that involves an encephalogram (EEG). This modality is utilized to improve brainwave activity, particularly in patients with anxiety disorder. The study by Surmeli and Ertem evaluated 36 patients with obsessive-compulsive disorder who were treated with neurofeedback. Per the authors, 33 out of 36 patients who received neurofeedback training showed clinical improvement. The authors noted that the study provided good evidence for the efficacy of neurofeedback treatment in obsessive-compulsive disorder. In this patients case, despite psychotherapy and Lexapro, he continues to be symptomatic. Treatment with biofeedback is appropriate in this clinical setting. In sum, biofeedback therapy is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1 and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry 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: Upheld

A 43-year-old female enrollee has requested for Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that the standard of care medications for the treatment of fibromyalgia include Cyclobenzaprine and Gabapentin. Although Lyrica can be effective in some patients with a diagnosis of fibromyalgia, such is also true of the other standard medications.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopy, surgical, esophageal sphincter augmentation procedure (CPT code 43284). Findings:  Two of the three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, laparoscopy, surgical, esophageal sphincter augmentation procedure (CPT code 43284) is not likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services are 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 60-year-old female enrollee has requested a power wheelchair for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that based on the clinical information provided for review, the patients functional status does not meet the evidence based guidelines for use of a power wheelchair. The lower limb motor strength in physical examination on the date indicated was not consistent with the patients functional status determined during a physical therapy evaluation on the date indicated, or with physical examination findings by her pain management physician on the dates indicated. Motor strength of the lower limbs was graded 1/5 on the date indicated, but was 4+/5 during the physical therapy evaluation. Given these findings, an updated physical therapy mobility evaluation is required before it can be determined if the patients functional status meets the criteria for a power wheelchair versus a manual wheelchair. Therefore, the requested power wheelchair is not supported as medically necessary for treatment of this patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A forty-seven year old male with low back pain is requesting authorization for artificial disc replacement utilizing the Charite artificial disc.Reviewers' Findings:The three reviewing physicians found that the proposed artificial lumbar disc replacement is still an experimental procedure. There is no Class I, long-term outcome data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is still unknown and complications may be severe. The proposed artificial lumbar disc replacement is still an experimental procedure. There is no Class I, long-term outcome data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is still unknown and complications may be severe.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested single photon emission computed tomography (SPECT) scans and selective internal radiation therapy (SIRT) and vascular embolization/occlusion (CPT 37243) for medical evaluation and treatment of his metastatic colorectal cancer.  Findings:  Two physician reviewers found that there is evidence that the use of Yitrium-90 may improve median survival in patients who have failed multiple regimens of chemotherapy.  However, there is a lack of prospective, randomized controlled trials supporting radioembolization for colorectal liver metastases. All told, the superior efficacy of SPECT and SIRT and vascular embolization/occlusion (CPT 37243) has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The Level of Care Utilization System (LOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. The patient had a risk rating of 3 for moderate risk of harm. The patient has been having passive, intermittent suicidal ideation with no plan. The patient excessively uses alcohol, which has resulted in harmful behaviors in the past such as getting a citation for drinking under the influence. His functional status was scored a 3 for moderate impairment. The patient is withdrawn and isolates. He lives alone and has not worked for many years. He has a conflictual relationship with his father, although his father is willing to participate in treatment. The medical/addictive/psychiatric comorbidity is scored a 3 which correlates to significant comorbidity. The patient has a comorbidity of alcohol use disorder and a sex and pornography addiction. His recovery environment is scored a 3 for moderately stressful environment. The patient has a conflictual relationship with his father who the patient feels is demanding and controlling. His level of support is also scored a 3 which correlates to limited support in environment. The patient has interpersonal problems with his father. However, the father is willing to participate in treatment even though from the record, it appears that his father is somewhat ambivalent. His treatment history is scored a 3 for equivocal response to treatment and recovery. The patient was successfully detoxed from alcohol. He has been drinking heavily for the last four to five years and has only been sober for 18 hours during that time.  His engagement and recovery status is scored a 2 which correlates with a positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. According to the LOCUS criteria, this patients total score is 20. As such, this patient would meet criteria for treatment at a partial hospitalization program (PHP). His comorbidities of pornography and sex addiction did not require the patient to be in a more restrictive environment for the treatment of his alcohol use disorder.  Therefore, residential treatment center services provided were not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old man with a three-year history of post-traumatic right head pain. He responded partially to occipital nerve blocks for two weeks, but developed tenderness at the site of injection. He had two weeks of pain relief after a right C2-3 nerve block and partial response to indomethacin. Lyrica was initially helpful at a dose of 50mg. The dose was subsequently increased, but the patients response is not documented. He is now seeking authorization and coverage for botulinum toxin injections. The Health Plan has denied his request on the basis that the requested injections are not medically necessaryThe patient has post-traumatic pain syndrome involving the right side of the head. He did respond to a C2-3 block, occipital nerve block and Lyrica, to some degree. The records indicate the patients pain is usually mild and not disabling. There is no evidence the patient has been tried on a variety of standard therapies including tricyclic antidepressants or antiepileptic drugs that have been useful for pain (e.g., topiramate, gabitril, etc.). In addition, another trial of nerve root block may be appropriate in this setting. Furthermore, although botulinum toxin has reasonable data in the treatment of chronic migraine, there are only scattered case reports of its use in occipital neuralgia. All told, there are multiple standard therapies, which have not been utilized in this case and should be attempted prior to consideration of botulinum toxin.For the reasons set forth above, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male with a history of bronchiectasis secondary to common variable immune deficiency and restrictive lung disease. The patients provider indicates the patient has not been prescribed a Flutter device because he would not be able to perform the technique due to coughing episodes that occur with increased shortness of breath. In July 2003, it was noted the patients clinical condition was worsening. It was suspected that the patient might have bronchiolitis obliterans with organizing pneumonia. The patients condition was observed clinically with serial CT scans. The patients provider has recommended use of the Vest Airway Clearance System (the Vest) in order to improve secretion clearance. The Health Plan has denied authorization and coverage for the Vest on the basis that it is not medically indicated.There are many studies, which demonstrate that enhancing mucus clearance in patients with pulmonary disease results in a benefit in disease control and symptoms. Methods to enhance mucous clearance include the use of chest physiotherapy, postural drainage, and mucolytics. Though the Flutter device has not been prescribed for the patient because of potential coughing, coughing is the bodys primary method of secretion clearance. The patient can also perform postural drainage without assistance, which may be more effective after using the Flutter device or receiving a bronchodilator treatment. Given the availability of other modalities, the Vest is not medically indicated for the patient. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza to be used in conjunction with Sovaldi for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) 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. Guidelines further state that The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by a sustained virologic response. In this case, the patient has F2 fibrosis, and delaying treatment would result in further progression of fibrosis. Per AASLD guidelines, daily sofosbuvir and ribavirin plus weekly peg-interferon for 12 weeks is recommended for peg-interferon eligible treatment-naive patients with HCV genotype 3 infection, as a Class I, Level A rating. In addition, daily daclatasvir and sofosbuvir for 12 weeks (no cirrhosis) or 24 weeks with or without ribavirin (cirrhosis) is recommended for treatment-naive patients with HCV genotype 3 infection who are peg-interferon-ineligible/intolerant, as a Class I, Level A rating. Based on the documentation submitted for review, the patient does not have a contraindication to interferon. The patient has mild thrombocytopenia with a platelet count which does not make him ineligible to interferon-based regimen. All told, the request for Daklinza (daclatasvir) to be used in conjunction with Sovaldi for 12 weeks has not been established as medically necessary in this clinical setting.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician 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:  An enrollee has requested durable medical equipment (DME) items external ambulatory infusion pump, external transmitter, continuous glucose monitor (CGM) disposable sensor, and CGM SY external receiver for treatment of his diabetes with hypoglycemic unawareness. Findings:  The physician reviewer found that this patients records do not include a clinical indication for the requested equipment in order to properly manage his diabetes. There is no reason given why the patient needs a new CGM and pump. Further, the requested system has not been demonstrated to be superior for management of this patients condition when compared to the current CGM and pump already in use. Accordingly, the requested DME items external ambulatory infusion pump, external transmitter, continuous glucose monitor (CGM) disposable sensor, and CGM SY external receiver are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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.