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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The progress notes indicate that since she started IOP level of care, the patient has made some improvements behaviorally as well as psychiatrically. She was noted to continue to have a stressful relationship with her family. Thus, continued group, individual, and family therapy will likely be beneficial for the patient. She has reported episodes of self-harm behavior in the last several weeks. Applying the Child and adolescent level of care utilization system (CALOCUS), the patient continues to require the IOP level of care in order to manage her impulsivity and suicidal ideation. Current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy (DBT). As indicated by colleagues, a stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. Given the patients continued need for continued group, individual, and family therapy, the IOP at Insight Treatment Program was and is medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia injections. Although the patient is being treated with Femara, the records provided for review do not document that she has tried and failed bisphosphonate therapy. In addition, there is no report that the patient has developed an intolerance or has a contraindication to first-line therapy with either an oral or an intravenous bisphosphonate. The literature does not support the use of Prolia over bisphosphonates for treatment of this patients osteoporosis or bone pain. Becorpi and colleagues concluded that, bisphosphonates reduce the risk of vertebral fracture by 30-70% in people with osteoporosis. Researchers noted that, bisphosphonates are utilized routinely in breast cancer. However, the authors concluded that, In patients with osteolytic lesions or hypercalcemia, zoledronic acid is superior to pamidronate. In this clinical setting, the medical literature supports treatment with a first-line therapy available on the Health Plans formulary such as alendronate, Boniva, Actonel, or Reclast. For these reasons, the requested Prolia injections are not medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MitraClip procedure (transcatheter mitral valve repair). This patient has symptomatic severe mitral insufficiency, atrial fibrillation, and severe prolapse of the mitral valve. She remains significantly symptomatic on medical therapy. Based on her symptoms and her specific clinical situation, she has an indication for mitral repair. Given her comorbid conditions of poor wound healing and extremely low body weight as well as chronic treatment with steroids and immunosuppressive therapy, she is deemed too high-risk for open surgical repair of the mitral valve. She was evaluated for MitraClip therapy given her clinical features in the setting of a high operative risk. As she has multiple high-risk features for open surgical repair, MitraClip repair is likely to provide improved functional status as compared to standard available interventions. This patient meets published criteria for the MitraClip procedure, which is U.S. Food and Drug Administration (FDA) approved for this indication. Given these findings, the requested MitraClip procedure (transcatheter mitral valve repair) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MitraClip procedure (transcatheter mitral valve repair) is 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 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, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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

The parent of an eight-year-old male enrollee has requested  testing for the MTHFR gene mutation for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the testing at issue.  There is no rationale provided to justify testing for the MTHFR gene mutation.  There is no mention of a family history or personal history of thrombosis.  The MTHFR variants have a poor predictive value for future thrombosis.  The current medical evidence does not support the testing at issue in this clinical setting.  Per the most recent recommendations from the American College of Medical Genetics, MTHFR testing should be dropped from thrombophilia panels.  All told, testing for the MTHFR gene mutation was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc. The submitted documentation supports the requested medication in this clinical setting. The medical literature supports the use of viscosupplementation for osteoarthritis of the knees. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Per the authors, viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, Orthovisc is medically necessary for the treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee requested authorization and coverage of the medication Phentermine for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for a replacement feeding chair for treatment of the enrollees medical condition. Findings:  The physician reviewer found that this replacement feeding chair will facilitate safe feeding, and promote easy access to this patient. This patient has spastic cerebral palsy, and in an episode of choking or aspiration, quick and easy access is imperative. In addition, this chair may prevent the need for gastric feeding tube (G-tube) placement, which is a concern in this patient population. All told, the requested equipment is necessary for the patients safety and well-being and is not a convenience item.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cialis for treatment of his erectile dysfunction secondary to finasteride.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient presents with ED secondary to finasteride. The treating provider recommends continuing finasteride and adding Cialis for treatment of ED.  Finasteride has been shown to cause ED. Given that the providers treatment plan includes continuing using finasteride, Cialis is medically necessary to treat ED.  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 urology 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 Cytomel for treatment of his medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medication at issue was not medically necessary for treatment of the patients medical condition. Most patients with hypothyroidism, a condition in which the thyroid produces insufficient amounts of thyroid hormone, will require lifelong thyroid hormone therapy (Gaitonde, et al). Upon reviewing this patients laboratory data, it appears that he is persistently biochemically thyrotoxic, likely over-replaced on thyroid hormone medication.  Further, the documentation submitted for review does not demonstrate intolerance to generic liothyronine or an adverse effect from it. Given the above, Cytomel has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was 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.
Appeal type: Medical Necessity
Decision: Upheld

A forty-three year-old male with bipolar disorder and anxiety is seeking authorization for Cymbalta 60mg twice a day.Reviewers Findings:  The reviewing physician found that Cymbalta in a dose greater than 60mg per day is not FDA approved.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested the Bioness H-200 medical device (functional electrical stimulator) for treatment of his left hand paresis status post stroke.  Findings:  Three physician reviewers found that in this situation the prescribed functional electrical stimulation device is still an unproven device (Weber, et al.). The studies to date are small case reports involving patients with stroke, multiple sclerosis, and spinal cord injury (Hill-Hermann, et al.). The available literature does not present evidence for long-term functional change beyond standard care for functional electrical stimulation involving either the upper or lower extremity (Weber, et al.; and Stevens and Hunsaker). In sum, the requested device has not been shown to provide any advantage over standard care for treatment in stroke. Therefore, the denial was appropriate and the use of this device remains of unproven efficacy in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee requested residential level of care for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this patients case, substance use was problematic despite enhanced outpatient services.  However, she possessed several positive biopsychosocial factors and had not failed the intermediary setting of partial hospitalization.  The patient did not have a psychiatric illness or medical condition that required a 24-hour supervised setting.  Additionally, she was not having difficulty maintaining her self-care or activities of daily living.  The documentation provided does not support the clinical need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, residential level of care was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for Aciphex for  her gastroesophageal reflux disease. Findings:  The physician reviewer found that Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. Interpatient variability has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for braces. Based on the available documentation, the providers submitted HLD score of 26 noted by the provider was overcalculated. The major discrepancy in the submitted HLD score and the records is in the scoring of the anterior-posterior (AP) spread. The provider submitted an 8 mm AP spread, which is not supported by the photographs provided for review, which supports an AP spread of 4 mm. Based on the records, the HLD index review included an overjet of 4 mm, overbite of 3 mm, anterior crowding for 5 points on the upper and 5 points on the lower, and an AP spread of 4 mm, for an HLD index score of 21. The records support a score of 21 on the HLD, which is below the required threshold to support a medical indication for the requested braces and associated orthodontic services. As with any malocclusion, orthodontic correction would aid in the patients ability to chew and tear food and aesthetics, so the requested treatment would benefit the patient functionally. However, there is a lack of evidence of a health condition caused by the current occlusion to support that the requested procedure is necessary for the patient to achieve adequate nutrition. The patients mother states that the patient bites cheek, has a lisp due to malocclusion, and has very crowded teeth. Overall, the records do not demonstrate that the patient has any significant health issues related to the requested orthodontic services to support the requested treatment with a HLD score below the threshold recommended for the requested orthodontic services. All told, the requested braces are not necessary to prevent disease and promote oral health, or restore oral structures to health and function.Final Result: The reviewer determined that the requested services are not 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: The enrollee has requested authorization and coverage for Vantas 50 mg kit implant for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that According to current medical literature, prepubertal suppressive therapy in pediatric patients diagnosed with gender dysphoria is not medically necessary. Medications have been used off label for pubertal suppression in gender dysphoric children including two that are approved for the treatment of precocious puberty: leuprolide by intramuscular injection and histrelin (Supprelin LA), a subcutaneous implant with yearly dosing. However, there are no available medications that have current U.S. Food and Drug Administration approval for suppressing physiologic hormonal development in pediatric patients with gender dysphoria. Through suppression of the hypothalamic pituitary axis, these agents prevent development of secondary sex characteristics, but also inhibit bone growth and interfere with estrogen- or testosterone-dependent brain maturation and inhibit fertility. Additionally, the American College of Pediatricians do not recommend prepubertal suppressive therapy in gender dysphoria patients. While this patient may have longstanding history of gender nonconforming behaviors, including statements of wanting to be a girl, there is a lack of support in the medical literature to support its use for prepubertal pediatric patients who are diagnosed with gender dysphoria. For these reasons, Vantas 50 mg kit implant is not medically necessary for 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone 15 mg five tablets per day for treatment of the enrollees neck and back pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented to be done. Thus, the need to use them as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking 112.5 MME per day. However, there is a lack of medical evidence based rationale for this high of MME per day. Also, the records suggest that tolerance has taken place since the patient was started on narcotics and there is also the possibility of opioid induced hyperalgesia. All told, the requested authorization and coverage for oxycodone 15 mg five tablets per day, 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Afrezza inhalation powder. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients type I diabetes mellitus with hyperglycemia. The submitted documentation does not support the medical necessity of the requested medication. Fala and colleagues, state that Afrezza, (insulin human) inhalation powder is a rapid-acting technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin. Although it achieved the pre-specified non-inferiority margin of 0.4 percent, as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes, who received Afrezza, demonstrated less reduction in hemoglobin A1c levels. All told, while there is some evidence supporting the use of Afrezza insulin, it is not sufficient to support the need for this medication in this patient rather than injectable insulin. Therefore, Afrezza inhalation powder is not medically necessary for 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 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 a similar medical condition.