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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for isotretinoin capsules.Autosomal recessive congenital ichthyosis (ARCI) is a heterogeneous group of nonsyndromic disorders of keratinization, which includes lamellar ichthyosis (LI), congenital ichthyosiform erythroderma (CIE), and harlequin ichthyosis (HI). In addition to cosmetic problems, ichthyosis patients usually suffer from a series of medical problems that are directly or indirectly related to pathomechanisms which are also potential targets for therapy. The symptoms include: pruritus, painful fissuring of the thickened skin, decreased range of motion at joints, decreased tactile sensitivity especially of the fingers, hypohidrosis with heat intolerance, a liability to skin irritation, and, in some cases, an increased tendency to skin infection. The range and severity of symptoms usually vary considerably from one patient to another and may also change over time in one and the same patient. This makes it essential always to adjust therapy according to the patients individual and current needs.Symptomatic treatment with emollients and topical keratolytics remains the mainstay therapy for ichthyosis, and should be maintained also when adjuvant systemic agents are prescribed. Glycerol, urea, and propylene glycol are the most commonly used hydrating ingredients, usually in cream formulations. Three important mechanisms are involved in the action of topical agents used in the treatment of ichthyosis: hydration, lubrication and keratolysis. The latter effect can also be achieved with systemic retinoids. Retinoids have keratolytic effects that facilitate the shedding of scales from the surface and prevent excessive hyperkeratosis, thus leading to a more normal thickness and improved function of the horny layer.In this case, the patient has been diagnosed with autosomal recessive congenital ichthyosis. The medical literature supports the use of systemic retinoids such as isotretinoin for their keratolytic effect in the treatment of ichthyosis. The patient has been on isotretinoin and the medication has already shown high clinical efficacy. Under these circumstances, isotretinoin capsules are 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that the Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. The patient had nausea with Viread requiring discontinuation, but may not experience the same effect with Vemlidy due to different concentrations of the prodrug and active drug forms of tenofovir in various tissues.  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

The parent of a 14-year-old male enrollee has requested reimbursement for admission and services provided at a psychiatric hospital for three days for treatment of the enrollees obsessive compulsive disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient was in a state of severe decompensation at the time of psychiatric admission. He was completely incapable of caring for himself and had been treated as an outpatient without substantial improvement. Further, he expressed suicidal thoughts and was completely incapable of functioning. During the period under review, the patient meets the American Psychiatric Association (APA) criteria for inpatient level of care based on these facts, as he was an acute danger to himself. Thus, the inpatient services provided services provided are supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nitro-Bid ointment. There is limited evidence to support the use of specific medications for chronic intermittent finger gangrene and lupus anticoagulant syndrome. Similar to other hypercoagulable states and collagen vascular disease, the use topical vasodilators are beneficial when there is tissue hypoxia similar to Raynauds syndrome. There is evidence for the use of calcium channel blockers in this case . Nitroglycerin is often used in the acute ischemic phase. In this case, the patient does not have any abnormal findings of the fingers on physical examination. The patient remains on aspirin and Nifedipine for prevention. However, there is no indication that Nitro-Bid ointment is superior to generic nitroglycerin or other formulations for use in this clinical setting.Therefore, the requested Nitro-Bid is not medically necessary for treatment of this 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 family practice with expertise in wound management 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. For the reasons provided, digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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: All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested a gastrointestinal (GI) tract wireless capsule endoscopy for medical evaluation of her abdominal pain, diarrhea, nausea, and vomiting.  Findings:  Two physician reviewers found that the accepted indications for capsule endoscopy include obscure GI bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes. The medical guidelines noted that the wireless capsule endoscopy can be used in evaluation of the small bowel for tumors such as lymphoma, carcinomas or carcinoids. This patient meets none of these indications. For these reasons, the requested GI tract wireless capsule endoscopy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested diagnostic procedure is 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

An 88-year-old male enrollee has requested for Thalomid 100 mg for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the use of Thalomid with or without other antineoplastic medications is being studied in clinical trials. The authors of the available clinical literature all agree that additional studies are needed to assess the effect and duration of response to this agent. Early results are described as encouraging with respect to lowering the PSA and perhaps median survival. However, the use of Thalomid is not currently supported for prostate cancer at any stage, nor is there evidence in the peer-reviewed literature demonstrating that it may be superior to standard therapies in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested authorization and coverage for the laparoscopic Roux-en-Y procedure.   Findings:  The physician reviewer found that this patient has a history of obesity and is status post the laparoscopic adjustable banding procedure, and this has been complicated by issues with the port and erosion of the band.  However, the submitted documentation does not demonstrate the medical necessity of the requested procedure at this time.  There is no dietary or behavioral evaluation documenting the patients ability to comply with the dietary differences associated with a gastric bypass.  In this patients case, a standard multidisciplinary evaluation, including a more recent dietary and behavioral evaluation, is needed, as there are additional differences between the laparoscopic adjustable gastric banding procedure and gastric bypass.  Absent this documentation, the medical necessity of the requested laparoscopic Roux-en-Y surgery has not been established at this time.  Therefore, the requested procedure is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orenitram ER for treatment of his medical condition.  Findings:  Three physician reviewers found that the management of pulmonary arterial hypertension (PAH) was initially limited to continuous intravenous infusions of prostacyclin, a difficult drug to administer and tolerate. In the past several decades there has been a significant increase in the number of compounds available and methods of administration. Recent data on the management of PAH found that among treatment naive patients, a two drug regimen demonstrated a significantly lower risk of treatment failure than starting drugs individually. With that in mind, the current issue is whether a patient already on a two drug regimen would benefit from the addition of a third drug, in this case a prostanoid (a class he is not on) and what the route of administration should be. Trepostinil, the compound recommended, is a prostacyclin analogue available as a subcutaneous infusion (Remodulin), inhaled solution (Tyvaso) and a pill (Orenitram). Regarding this patient in particular, he is already on a proven two drug regimen and he is beginning to decline clinically with complaints of worsened exercise tolerance and physiologically (exertional hypoxia) and physically (worsening echocardiogram). Given the above indications, the patient would benefit from more aggressive therapy.  Therefore Orenitram ER, is likely to be a superior drug therapy than any available standard therapy for treatment of this patients PAH.  Final Result: Three reviewers determined that the 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 internal medicine with sub-specialty certification in pulmonary disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for deep brain stimulation. Findings:  The physician reviewer found that The American Psychiatric Association (APA) recommends that somatic therapies such as deep brain stimulation should be considered only after first- and second-line treatments and well-supported augmentation strategies have been exhausted. Per the guidelines, first-line treatments are CBT, selective serotonin reuptake inhibitors (SSRIs), and clomipramine. Second-line treatments include augmentation with other medications such as antipsychotics, stimulants, modulators of glutamate receptor, and other agents like ondansetron and naltrexone. A published review by international experts on strategies for the treatment of OCD recommends the use of neurosurgical treatments such as deep brain stimulation for patients with severe symptoms that have not responded to available medications and psychotherapies. As noted in the medical records provided for review, this patient has failed multiple first-line and second-line treatments for OCD. The patient has a documented history of treatment refractory OCD. 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: all three physician reviewers are 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 53-year-old female enrollee has requested telephone consultations (check-ins) with her psychotherapist for treatment of her major depression and post-traumatic stress disorder.  Findings:  The physician reviewer found that trauma-focused psychotherapy, such as cognitive processing therapy and prolonged exposure, remains the evidence based therapeutic intervention of choice for patients with PTSD. In addition, cognitive therapy is a well researched modality in the treatment of depression, and is useful for patients with dissociative episodes. Further, community based support groups and psychosocial interventions can often bridge symptomatic gaps. Based on symptom severity, services may need to be transiently delivered at a higher level of care, such as the partial hospital or residential setting. However, the medical literature does not demonstrate the utility of augmentative telephone consultations as part of such treatment plans. Overall, there are no well controlled, appropriately designed studies in the medical literature that demonstrate the efficacy of telephone consultation (check ins) in routine treatment for patients suffering from mood, dissociative or trauma-based disorders. Therefore, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for DecisionDX-Melanoma. The enrollee underwent a punch biopsy of a mole on her right frontal scalp. The pathology report showed melanoma. The DecisionDX-Melanoma genetic test assay was ordered. The report indicates the DecisionDx-Melanoma class was 1, and the sub-class was 1B. A class 1B signature is associated with a low risk of recurrence within five years. The results of the DecisionDX-Melanoma test revealed the claimant as class 1 B, which suggests a very low risk of metastatic potential. Furthermore, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this claimant. The DecisionDX-Melanoma assay was not known to be effective at the time it was performed, based on a lack of scientific evidence showing the results will accurately guide individual care and health outcomes. In this case, the testing would not have been considered effective or useful in treatment planning. The initial evaluation for risk of metastasis in those with cutaneous melanoma uses professional society staging criteria. The DecisionDx-Melanoma gene panel is not recommended by any standard treatment guidelines.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Pain Management 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with an immunologist/allergist within five miles of the enrollees residence for treatment of the enrollees persistent respiratory disease and multiple chemical sensitivity. Findings:  The physician reviewer found this is a case of a patient with multiple chemical sensitivity (MCS), chronic rhinosinusitis, chronic cough, common variable immune deficiency (CVID), and severe reactive bronchospasm. The records contain a diagnosis of severe hyper-reactivity but fail to provide supporting documentation such as pre- and post-pulmonary function tests (PFTs), emergency department visits, clinical findings of asthma, and bronchodilator use. In addition, vasomotor rhinitis and cough are noted as symptoms but further description of flare is not provided in the documentation. According to the American College of Occupational and Environmental Medicine (ACOEM), therapy is to be individualized to the patient in the clinical setting of idiopathic environmental intolerance (IEI). Focus continues to be on a patients triggers and ameliorating factors, while avoidance continues to be the best treatment strategy. The ACOEM guideline states that, there are no proven or effective treatments for IEI. Although it is not clear whether psychologic symptoms are the cause of IEI or whether they merely accompany the diagnosis, cognitive and behavioral interventions such as relaxation techniques, breath-control exercises, and a structured plan to increase overall physical and social activity (lifestyle changes) may be useful in the treatment of IEI. The records fail to demonstrate that she is home bound or otherwise limited. Overall, the medical records fail to demonstrate clinical findings supporting the medical necessity of an immunologist/allergist within five miles of the patients residence. Final Result: The reviewer determined that the 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 internal medicine with sub-specialty certifications in allergy and immunology and rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested abdominoplasty; abdominal panniculectomy; and bilateral thighplasty for treatment of her massive weight loss. Findings:  The physician reviewer found thatIn this case, the patients massive weight loss led to a significant deformity that had previously been treated with surgical correction. However, at this time there is insufficient medical documentation to warrant further surgical resection. Thus, the medical necessity for the requested services has not been established.  Furthermore, the requested services do not meet reconstructive surgery criteria. Based on the photographic documentation and the medical documentation submitted for review, there is insufficient evidence that a significantly abnormal condition is present. Therefore, as supported by the peer-reviewed literature, the requested services are not reconstructive in nature and not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested artificial disc replacement surgery and subsequent hospitalization for the treatment of her neck pain. Findings:  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  At this time, the potential problems that may occur with longer follow-up have not been fully documented.  Total disc replacement has been associated with a high rate of re-operations.  This patient has severe cervical spondylosis with foraminal impingement.  The standard procedure in this setting would be a single level anterior cervical discectomy and fusion.  There is a lack of truly blinded studies establishing the efficacy of the services at issue in this setting, and the results are short-term at best.  All told, the services at issue were not likely to have been more effective than other treatment modalities.