Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing she received. Findings:  Three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), myeloperoxidase, C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing provided was not likely to have been more beneficial than other available modalities for evaluating this enrollee. Final Result: The 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. Therefore, the Health Plans denial should be upheld. The reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Credentials/Qualifications: 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

The patient is a 29-year-old female who has requested authorization for Provigil for the treatment of depression related fatigue. She has been diagnosed with manic-depressive disorder. Her excessive fatigue was attributed to psychiatric medications such as Abilify, Celexa and Topamax. She has failed alternatives such as Seroquel, Lamictal, and Wellbutrin. Based on a fatigue severity scale, a 20% decrease in fatigue was attributed to Provigil. At issue is whether Provigil is medically necessary for treatment of the patients medical condition.Provigil for excessive fatigue is not an FDA-indicated use. The use of Provigil as a part of polypharmacy to offset the sedating effects of the patients psychiatric medications is not medically necessary or indicated. Provigil in this clinical setting is not based on a peer-reviewed, controlled trial. This off-label use of Provigil encourages polypharmacy and is not recommended. Eliminating sedating antipsychotics or reducing the dosing may have the same effect on the patients fatigue as Provigil. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Saizen growth hormone for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the records document that this patients height is more than two standard deviations below the mean for age and gender. In addition, his height velocity off growth hormone therapy is poor and his bone age is delayed. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of growth hormone deficiency. This patient meets most of these criteria. Accordingly, the requested Saizen growth hormone is supported as medically necessary for treatment of this patients short stature.  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 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

This patient is a 55-year-old male with obstructive sleep apnea (OSA) and associated cardiac arrhythmias (PACS and/or PVCS) as documented in two sleep studies at a sleep disorder center. Based on the results of these sleep studies, recommendations were made for various oral appliances, DDS/ENT surgical procedures, nasal strips, or NCPAP. The patient has been shown to be intolerant of CPAP and he has had internal nasal surgery including turbinectomies. A dental provider specializing in the fabrication and management of dental occlusal splints for a variety of medical problems has provided a repositioning device for treatment of his OSA. Sleep apneas continue to be a problem for the patient. The patients request for reimbursement for the cost of the oral device and related services was denied by the Health Plan citing a lack of medical necessity.Treatment with an occlusal splint is one of the recommendations made by the specialist at the sleep center for treatment of the patients OSA and documented cardiac arrhythmias. Anterior repositioning of the mandible with an oral appliance is a reasonable alternative to surgical repositioning of the base of the tongue or the entire mandible/maxilla complex. A review of the dental records for this patient indicates that the dental provider has attempted all of the usual fine-tuning maneuvers to obtain a satisfactory result from the splint. The occlusal device and related services provided to the patient are medically  appropriate  for management of his OSA.Based upon the information set forth above, I have determined the device and services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested participation in the autologous stem cell transplant randomized SCOT clinical trial for treatment of her systemic sclerosis.  Findings:  Two physician reviewers found that this patient has debilitating and progressive scleroderma that is recalcitrant to basic approved therapies. She has been on immunosuppressives such as azathioprine, methotrexate and steroids, although her disease has been progressive, and she has not tolerated these therapies very well.  High-dose chemotherapy with autologous stem cell transplant has been tried in scleroderma patients with some success.  This patient has a terminally progressive disease. The patient has requested coverage for enrollment in a clinical trial testing autologous hematopoietic stem cell transplant versus pulse dose cyclophosphamide for her disease. Both arms of the randomized clinical trial are supported by the medical literature as being efficacious.  All told, the requested services are likely to be more efficacious than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program services for a minimum of eight weeks. In this particular case, the patients roles, perspectives, experiences and symptoms cause significant intrapsychic distress and impairment in functional domains. She has had difficulty maintaining relationships. She struggles with periodic suicidality. She has recurrent depression with anxious distress, which is a combination that is both difficult to treat and associated with poorer outcomes.  Per the records, she has neither championed the second individuation nor consolidated her identity. Service delivery in the outpatient setting was not sufficient. She did not successfully complete the initial episode of intensive outpatient program treatment. While in the program, the provider opined that another eight weeks of intensive outpatient program services would be expected. Based on the records, treatment cannot reasonably be conducted in a less restrictive setting, as less intensive treatment is likely to result in inadequate care. The intensive outpatient program setting is reasonably expected to both improve her condition and prevent a more serious episode of illness. Further, the intensive outpatient program setting represents a safe and appropriate placement consistent with good medical practice. Thus, intensive outpatient program services for a minimum of eight weeks are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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: The patient has requested authorization and coverage for Trulicity 1.5 mg/0.5 mL pen. The records provided for review demonstrate that this patients type 2 diabetes mellitus is poorly control with a hemoglobin A1C of 8.8% on a regimen of metformin with glimepiride. As recommended by the American Diabetes Association (ADA), a target hemoglobin A1C should be less than 7% to decrease the risk of vascular complications. The ADA also encourages diet management and weight loss for improved glycemic control. The patients records demonstrate that she lost two pounds with diet management and continued on metformin and glimepiride, and her hemoglobin A1C had improved to 7.4%. After initiating Januvia, which is a dipeptidyl peptidase 4 inhibitor (DPP4-i), this patients hemoglobin A1C increased to 7.7% with further decrease in her weight. Due to the rise in hemoglobin A1C, her provider recommended the addition of Trulicity to her current combination of metformin, glimepiride, and Januvia. Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1). According to the ADA, the current data have not established a clinical role for the combined use of a GLP-1 agonist and a DPP4-i in this clinical setting. Therefore, the requested Trulicity 1.5 mg/0.5 mL pen is not medically necessary for 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 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 60-year-old female enrollee has requested Lucanix for treatment of her metastatic non-small cell lung cancer. Findings:  Three physician reviewers found that Lucanix is an anti-tumor vaccine that inhibits transforming growth factor beta-2.  In 2006, Nemunaitis published a report of treatment of 75 patients with non-small cell lung cancer. In this study, the authors compared two doses and found that patients on the higher dosage had improved survival. There was no comparison of these patients with patients treated in other ways. The authors concluded that there was a suggestion that this inhibition might be of survival benefit, and that further study was warranted. The most promising results of vaccine therapy of non-small cell lung cancer involved patients with early or locally advanced stages of disease.  This patient has widespread disease (Gridelli and colleagues).  At this time, there is insufficient data demonstrating that Lucanix is likely to be of clinical benefit in a patient with advanced disease.  Therefore, in this patients case, Lucanix from the said date and forward was not and is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL pen injector.The submitted documentation supports that the requested medication is medically necessary. In this case, the patient has multiple risk factors for coronary artery disease (CAD) as well as some calcification on CT scan. The patient failed to reach his LDL goal with conventional statin/ezetimibe therapy. In addition, he has already been maintained on PCSK-9 inhibitor for many years with a very good LDL response and no side effects. Based on this significantly elevated cardiac risk and his failure to adequately respond to conventional two drug lipid lowering therapy, Repatha PCSK-9 inhibitor therapy is both medically necessary and appropriate for treatment of his severe hyperlipidemia. Accordingly, the requested medication Repatha Sureclick 140 mg/mL pen injector is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 cardiovascular disease, 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 a continuous glucose monitor for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested services have been established as medically necessary in this clinical setting. The patient has wide glycemic excursions, nocturnal hypoglycemia, and poor overall glycemic control despite adherence to a regimen of insulin pump therapy and frequent blood glucose monitoring.  His eating habits and activity are not always predictable, and he cannot express symptoms of hypoglycemia or hyperglycemia. Continuous glucose monitoring is the only tool available to enable the parents to track glucose trends and to set parameters for alarms of high and low blood sugars. Knowledge of blood glucose trends will help prevent episodes of life-threatening severe hypoglycemia and severe hyperglycemia. Use of continuous glucose monitoring will enable his parents and medical team to develop more confidence in bolus dosing and fine-tuning of doses without having fear of hypoglycemia. These advantages are especially of importance in children who cannot express symptoms of hypoglycemia and hyperglycemia and who are at high risk of having life-threatening acute complications of type 1 diabetes. Feasibility studies have shown that more than 40% of young children are able to safely use continuous glucose monitoring on a near-daily basis (Tsalikian, et al). In addition, continuous glucose monitoring demonstrated frequent hyperglycemia and hypoglycemic excursions that may not have otherwise been detected. Given the above, the requested services are clinically indicated for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 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: Upheld

A 54-year-old female enrollee has requested gastric revision surgery from the previously provided Lap-Band to Roux-en-Y gastric bypass for treatment of her obesity.  Findings:  The physician reviewer found that the patient underwent Lap-Band for treatment of morbid obesity. Lap-Band is a restrictive procedure. There is a lack of published data that suggests that Roux-en-Y gastric bypass is more successful long-term when compared to the Lap-Band. OBrien and colleagues reported similar weight loss medium-term when comparing the Lap-Band to gastric bypass. The pouch of the Lap-Band and the gastric bypass operations are of very similar sizes. Significant weight loss with a procedure that causes the same degree of restriction as the Lap-Band procedure is not likely. Revision to another restrictive procedure is not indicated for this patient given its low probability of success.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female who had a four-month history of pelvic pain. In December 2003, an ultrasound revealed a 4.6cm dermoid cyst of the right ovary. A CA-125 was normal. The patient required a surgical procedure to remove the cyst due to the possibility of complications that could occur. Her provider recommended a mini-laparotomy. The patient consulted another provider who recommended a laparoscopy, which the patient ultimately decided to undergo. The Health Plan has denied reimbursement for the laparoscopy at issue. The Health Plan states that a mini-laparotomy is essentially the same operation as a laparoscopy.The type of cyst involved in this case can be removed by three distinct procedures. First, a laparotomy may be performed. A laparotomy involves a vertical incision from the umbilicus to the pubic area or a horizontal incision just above the pubic area that is approximately six to seven inches long. Both of these approaches would constitute major surgery. The second surgical option is a laparoscopy. A laparoscopy entails making a less than one-inch incision at the umbilicus and one or two incisions less than one inch each in the lower abdomen. This procedure is considered an outpatient procedure and is less traumatic due to the amount of tissue manipulation and recovery time that is involved.The third surgical option is a mini-laparotomy. A mini-laparotomy can be considered somewhat equivalent to a laparoscopy if it is performed in the manner of a bilateral tubal ligation, i.e., a one to three inch incision is made and delivery of the tubes or in this case the ovary is performed through the incision with retractors without complete visualization of the pelvic area. If it was the patients providers intention to perform the procedure in this manner it might be said that the mini-laparotomy was equivalent to a laparoscopy. However, a mini-laparotomy can also be considered as merely involving a shorter incision than a regular laparotomy, e.g., four to five inches instead of six to seven inches. In this case, the trauma and recovery period are perhaps somewhat improved, but certainly not comparable to the laparoscopy.Based upon the recovery time stated in the informed consent given by the provider who recommended the mini-laparotomy it appears his definition of mini-laparotomy was of the latter variety and therefore, akin to a more major procedure. Also, there was some notation that a mini-laparotomy had never been scheduled by these physicians before. In contrast, the provider who performed the laparoscopy clearly indicated a recovery time consistent with the less invasive procedure. Furthermore, while it has been stated that a laparotomy was needed because the ovary needed to be removed (rather than removal of the cyst only) an ovary can indeed be removed by a laparoscopy.Based upon the information set forth above, I have determined that the procedure at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for hip to ankle scanogram/EOS imaging. The Health Plan denied the request and reported the requested services are not medically necessary for the evaluation of this patient. Researchers concluded that the identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management. Per the authors, LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease. Medical literature states upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure. In addition, the ability of this technology to obtain images while subjects are standing upright makes this the ideal modality with which to assess limb alignment in the weight-bearing position. Researchers reported Russell-Silver syndrome is a rare condition associated with prenatal and postnatal growth retardation. Orthopedic problems associated with Russell-Silver syndrome include limb or body asymmetry, scoliosis, hip dysplasia and hand and/or foot anomalies. A limb asymmetry can affect the arms, legs or both. Limb lengthening surgery performed to equalize limb lengths in patients with Russell-Silver syndrome has shown positive results. In this case, the patient has been diagnosed with Russell-Silver syndrome and a right leg length discrepancy. He is being monitored on an annual basis to determine whether surgical invention is required to prevent permanent deformity and associated orthopedic problems. The medical evidence supports the requested services in this clinical setting. Therefore, hip to ankle scanogram/EOS imaging is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic 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.