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 Nutropin pen injector. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patients pre-treatment growth velocity was poor, and her adult predicted height was more than 2.25 standard deviations below the mean for her genetic target height and for adult population mean. Although they passed provocative GH testing and is not known to have a morphological abnormality of the pituitary gland, they meets U.S. Food and Drug Administration criteria for treatment of idiopathic short stature with poor adult height prediction that is below 59 inches. Therefore, Nutropin pen injector is medically necessary for treatment of this patient. Fnal 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the medication, Xultophy, 100 Unit-3.6 MG/ML pen. The enrollee has a past medical history of stage three chronic kidney disease; type 2 diabetes mellitus, complicated by retinopathy, nephropathy and neuropathy; coronary artery disease with a history of ST-elevation myocardial infarction, complicated by cardiac arrest, status-post percutaneous coronary intervention; congestive heart failure, gout, hypertension, psoriasis, heparin-induced thrombocytopenia, and adrenal insufficiency. A progress note indicates the enrollees diabetes regimen included Xultophy, 35 units at bedtime. The physician recommended the enrollee continue his current regimen, as he has done extremely well on this medication, with a recent hemoglobin A1C of 6.4 percent, and his glucose control is now at goal. The provider is recommending the enrollee continue his current Xultophy regimen to decrease his risk of further cardiac complications. The enrollee has limited choices of diabetic medications due to his poor renal function state. Review of the records indicates there were questionable low blood glucose readings in the early morning hours, which indicates the enrollee's blood glucose was not well-managed with insulin and oral medications. Low blood glucose, (hypoglycemia), is an adverse effect of insulin treatment and a sign of a poorly controlled regimen. Literature notes Xultophy is a combination of insulin degludec and liraglutide.  Xultophy may provide additional blood sugar control with fewer adverse effects for individuals uncontrolled on a glucagon-like peptide-1 receptor agonist or basal insulin alone. Xultophy offers clinicians another reasonable option for these individuals. Use of the combination agent Xultophy offers the advantages of improved efficacy compared with either agent alone, a reduction in hypoglycemia, and an improved weight profile compared with basal insulin. Literature notes the use of Xultophy resulted in significant reductions in hemoglobin A1C values and a statistically insignificant weight gain over 12 months. The use of Xultophy has proven effective in improving blood sugar control in individuals who are refractory to standard treatments. The records indicate the enrollee has been using Xultophy for the past year and has shown improvement in his hemoglobin A1C; from 8.7 to 6.7 percent. He also has coronary artery disease and literature shows that use of the individual components in xultophy, liraglutide and degludec, has helped to improve outcomes. 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 endocrinology, diabetes 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC. Oral immunotherapy is not currently recommended as a standard care for treatment of food allergies. Researchers concluded that while significant progress has been made in the last decade in food allergen-specific oral immunotherapy, it is still in the very early stages of development and further investigations are necessary to optimize the protocols and improve safety while maximizing efficacy. Researcher notes that further investigation is needed to address current knowledge gaps including optimal dose, duration, age of initiation, maintenance schedule, mechanisms, predictors of risk and therapeutic response. Researchers reported that oral immunotherapy is associated with higher rates of systemic adverse events compared with other forms of immunotherapy, as well as a minor risk of eosinophilic esophagitis. Although several studies appear to have found benefits in oral immunotherapy, the interventions and end points used in these and other published trials vary widely, and either have not included controls or have used a cross-over design. As a result, neither the safety nor efficacy of oral immunotherapy has been definitively established. As such, oral immunotherapy, and the associated food-specific immunoglobulin E (IgE) testing, are not the standard of care for management of food allergies. Therefore, Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Cybernetics Food Anaphylaxis Panel by Foundation Labs LLC is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 reviewer 1 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and pediatrics and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic array genome testing. Studies show polycythemia vera is a condition where autonomous production of red cells proceeds in an unfettered manner. If not appropriately treated, polycythemia vera may result in serious vascular thrombotic consequences. The expected erythrocytosis in this condition may be masked in patients who are iron deficient. In such cases, when iron is replenished, the hematocrit will rise into the polycythemic range. The provider in this patients case recommended the JAK2 assay to assist in appropriate diagnosis and treatment. The clinic notes indicate the patients hemoglobin reached 16.8 g/dL at one stage, which supports an indication for testing, since guidelines suggest consideration for polycythemia vera in males with hemoglobin levels above 16.5 g/dL. Given these findings, the genetic array genome testing was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the genetic array genome testing was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic array genome testing was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with lipedema. The patient endorsed leg and hip pain for over 12 years. A computed tomography (CT) scan of the patients abdomen was unremarkable. A venous ultrasound of the patients legs was noted to be normal. The patient complained of fullness in the upper and lower extremities with bruising, swelling, and pain that was not responsive to diet and exercise. The patient reported that the pain affects her activities of daily living. The patient has been treated with gabapentin, Voltaren gel, compression stockings, and ice and heat. a few months later, the patients body mass index (BMI) was 43. The patients photographs were reviewed. At issue in this case is whether lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modaities of Water Assisted Liposuction (WAL), VASER (ultrasonic), and Power Assisted Liposuction (PAL) using local anesthesia and manual lymphatic drainiage therapy are medically necessary for the treatment of the patients medical condition. As noted by researchers, lipedema is characterized most commonly by disproportionate adipocyte hypertrophy of the lower extremities, significant tenderness to palpation, and a failure to respond to extreme weight loss modalities. The authors found that due to lipedemas relatively unknown status in the medical community, there is a paucity of data regarding effective treatments of this disease. Relatively few studies have defined the precise pathogenesis, epidemiology, and management strategies for this disorder. This patients records do not document failure of conservative management, including significant weight loss, as the patient reportedly has a BMI of 43. Therefore, lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modaities of WAL, VASER (ultrasonic), and PAL using local anesthesia and manual lymphatic drainage therapy are not medically necessary for the patient. 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 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: The patient has requested authorization and coverage for laser hair removal. Treatment of pilonidal sinuses can be challenging as there are multiple modalities and options with varying rates of success and support in the current medical literature. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of pilonidal disease  provide a comprehensive summary of many treatment modalities for pilonidal sinuses. In particular, elimination of hair from the gluteal cleft and surrounding skin by shaving or laser removal is given a weak recommendation based on low quality evidence, and the guidelines do not include evidence that one modality, laser removal, is better than the other, shaving. The guidelines give surgical excision, which is considered a standard treatment for chronic pilonidal sinuses, a stronger recommendation based on moderate quality evidence. In this case, the records document that the patient has already undergone surgical management of the pilonidal cyst. Given the weak nature of the evidence supporting laser hair removal for the treatment of pilonidal sinuses, the requested service is not medically indicated. Therefore, laser hair removal is not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the records document that a pilonidal sinus has already been surgically removed, and the requested laser hair removal is for the potential prevention of a recurrence of pilonidal sinus. In this case, hair growth is not an abnormal structure of the body. The requested service is not to improve function, to create a normal appearance, or provide more than a minimal improvement in the appearance of the patient. Accordingly, the requested laser hair removal is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing provided for evaluation of the enrollees non-small cell lung cancer.Findings: Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) NSCLC guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, the FoundationOne testing provided was likely to be more beneficial for evaluation than available standard therapy to guide decision making.Final Result: The reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocortisone acetate 25 mg suppositories. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The American College of Gastroenterology guidelines for management of benign anorectal disorders do not recommend hydrocortisone acetate 25 mg suppositories over the formulary alternatives. The formulary alternative, hydrocortisone cream 1%, is effective based on current medical literature. There is a lack of high-quality controlled trials showing that hydrocortisone acetate 25 mg suppositories are superior to the formulary alternative, and there are no reported contraindications to the formulary alternative. Therefore, hydrocortisone acetate 25 mg suppositories are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

The patient has requested authorization and coverage for Freestyle Libre Sensors for glucose monitoring. The Freestyle Libre is a continuous glucose monitor (CGM) that is useful for diabetic patients for improving safety with frequent hypoglycemic events or with hypoglycemic unawareness. The device allows blood sugar readings to be obtained on an ongoing basis. With this information, the patient is allowed to adjust insulin dosages either prandially or at bedtime to avoid hypoglycemic events. Latent autoimmune diabetes in adult (LADA) is a type of diabetes that generally does not require insulin at diagnosis but may progress to insulin dependence in the future. In this case, the patient has LADA. No hypoglycemic events have been recorded and she has not been started on prandial insulin. She does have a history of chorioretinitis, but the records do not document the extent of the disease, or that the patient is unable to use a finger stick glucometer. Given these findings, Freestyle Libre Sensors for glucose monitoring are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medical supplies 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 expertise in endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xyrem for treatment of her medical condition. Findings: The reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The use of Xyrem in the treatment of narcolepsy is well-documented with current medical literature.  The patient has previously failed a trial of a central nervous system stimulant.  However, the records document concurrent prescriptions of multiple sedative agents which were prescribed by the patients non-sleep physician.  The use of benzodiazepines and other sedative agents is an explicit contraindication to the use of Xyrem.  In this case, there is no formal indication that the use of the sedative agents will be discontinued outside of a letter requested by the patient for submission to the insurance company.  In the primary interests of patient safety, given the history of benzodiazepine use and active prescriptions for such drugs, the request for authorization cannot be recommended for approval at this time.  The risk of an adverse outcome with the drug combination is too great.  All told, Xyrem is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 44-year-old male has requested Lyrica for treatment of his overuse tendinitis.   Findings:  Two physician reviewers found that the patient presented to his provider with pain in multiple joints. The patients primary complaint is bilateral knee and bilateral hand pain over the past year. The patients previous diagnosis was osteoarthritis of the hands, with initial prescriptions of hydrocodone and Celebrex. The patient was noted to have mild swelling over the extensor surfaces of his MCP joints. The patients right knee is slightly tender and all joints have full range of motion and no warmth no erythema. The patient has been diagnosed with overuse tenosynovitis of the forearms, possible early rheumatoid arthritis. The patient reported that Celebrex left a metallic taste in his mouth, and he was started on Tylenol 500mg two to three times daily. Laboratory testing on 5/10/12 were reportedly normal except for hemoglobin of 13.3 g/dL.  In this case, the patients diagnosis is considered an off-label indication for treatment with Lyrica. Although this patient does have debilitating disease process of the arms, as per the patients notation, there is a lack of scientific data supporting the use of Lyrica in patients with tendonitis. All told, there is no indication for use of Lyrica in tendonitis as noted in the peer-reviewed medical literature, and available therapies have not reportedly been exhausted.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested for Cerezyme for treatment of the enrollees Gaucher disease. Findings:  The physician reviewer found that medical records do not include documentation of the patients genetic potential for height. Thus, it is not known if the patients growth is retarded compared to his genetic potential. Children with growth retardation may be at greater risk of bone complications.Cerezyme is medically indicated if there is documented evidence the patient has either growth retardation or bone lesions.