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

The patients parent has requested authorization and coverage for tofacitinib (Xeljanz). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tofacitinib (Xeljanz) is medically necessary for treatment of the patients medical condition. Researchers reported that autoimmune-triggered non-scarring hair loss is a feature of alopecia areata (AA). Initially patchy and often self-limited, severe hair loss forms include the complete loss of scalp hair or alopecia totalis (AT) and complete loss of all hair or alopecia universalis (AU). Medical literature reported that Xeljanz (is an oral Janus kinase (JAK) 1/3 inhibitor that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe rheumatoid arthritis. Researchers also noted that after two months of treatment with tofacitinib, there was some improvement in psoriasis, with partial hair regrowth on the scalp and face. After three more months of treatment with tofacitinib, there was complete regrowth of the scalp hair, along with significant regrowth of the eyebrows, eyelashes, and facial hair. Researchers reported that systemically administered JAK inhibitors prevented the development of AA, while topical administration promoted hair regrowth and reversed established disease. In this case, the patient has been diagnosed with alopecia of the scalp, eyebrows, and eyelashes and has failed treatment with other medications. The medical evidence supports the requested medication in this clinical setting. Therefore, tofacitinib (Xeljanz) 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 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 Privigen immune globulin (IVIG), intravenous, non-lyophilized, 2 gm/kg, given over three to five days, every 3-4 weeks, for three times for severe, intractable small fiber neuropathy (HCPCS J1459).Liu and colleagues state, Small fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immune globulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Further, Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The author notes, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has small fiber neuropathy, which is thought to be autoimmune in nature. The patients symptoms have not been controlled with conventional medical therapy. Based on the studies noted above, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Privigen immune globulin (IVIG), intravenous, non-lyophilized, 2 gm/kg, given over three to five days, every 3-4 weeks, for three times for severe, intractable small fiber neuropathy (HCPCS J1459) are medically necessary for the treatment of the enrollee's 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 neurology 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 58-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees daytime sleepiness.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 depending upon documented evidence that a trial of nasal CPAP has failed and that a diagnosis of narcolepsy has been ruled out.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Hyalgan injection series in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Hyalgan injection series in both knees is 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 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: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee requested authorization and coverage of intradialytic peritoneal nutrition (IPN) for the treatment of chronic renal disease. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that intradialytic peritoneal nutrition is not likely to be more beneficial for treatment of the enrollees chronic renal disease than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a schedule 3 drug and Zomig for treatment of the enrollees migraines. Findings:  The physician reviewer found that Zomig is effective in treating acute migraine, but has little role in the management of chronic daily headache.  For the more severe migrainous type headaches, Zomig is a reasonable choice. However, use of this medication should not exceed 10 days per month.  There is no role for narcotic analgesics in the management of chronic headache.  Typically, narcotic use limits the effectiveness of preventive medications. Preventive medications are the best option in this clinical setting.  Furthermore, narcotics can be associated with worsening of headache consistent with medication overuse headache.  Therefore, Zomig is medically necessary for the treatment of this patient.  The medical records fails to demonstrate the medical necessity of a schedule 3 drug. Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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 56-year-old female enrollee has requestedmicrodecompression nerve release surgery and follow-up treatment for treatment of her occipital neuralgia.  Findings:  Three physician reviewers found that occipital neuralgia is a condition characterized by frequent and severe headaches.  The pain is located in the occipital area and may spread toward the vertex.  It is usually unilateral, but may be bilateral. The attacks can last for days, making even routine daily tasks difficult to accomplish.  The treatment plan for occipital neuralgia/occipital headache depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as patients age, ongoing medical conditions, and ability to tolerate other medical therapies. Standard therapy may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage.       Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes.  Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation.  At this time, the superior efficacy of occipital release surgery has not been proven.  All told, the requested microdecompression nerve release surgery and follow-up treatment are not likely to be the most efficacious treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Calquence (acalabrutinib) 100 mg capsules. The records provided for review document that this patients condition has been stable on ibrutinib, but with reported side effects including nausea, poor appetite, and fatigue. Although the patient reports side effects, the patient has not reached the lowest dose reduction for ibrutinib, which is 140 mg daily. Akhtar and colleagues evaluated 70 patients with CLL treated with dose reductions of ibrutinib to improve drug tolerance. The authors found no statistical difference in overall response rate (ORR), clinical benefit rate (CBR), median progression-free survival, and overall survival (OS) between the dose-reduced and standard-dose groups (SDGs). In addition, the National Comprehensive Cancer Network (NCCN) does not recommend treatment with Calquence for management of this patients CLL. In this clinical setting, switching to Calquence is not consistent with current guidelines and peer-reviewed medical literature. For these reasons, the requested Calquence (acalabrutinib) 100 mg capsules 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Fiasp FlexTouch insulin pen. Until recently, three rapid-acting insulin analogues, Humalog, Novolog, and Apidra, were the only analogues which were available as prandial insulins. Fiasp is insulin aspart enriched with two excipients, of which niacinamide is responsible for accelerating absorption after subcutaneous administration. As such, it is the first mealtime insulin without a pre-meal dosing recommendation. For this reason, it may add potential benefits to a pre-existing insulin regimen. However, there is a lack of data which suggests that it may be superior in efficacy to the previous insulin analogues, such as Humalog. The Health Plans alternative is medically appropriate in this setting. Therefore, the requested Fiasp FlexTouch insulin pen is 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 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: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has vertebral fracture assessment (CPT 77082) for evaluation of her osteopenia.   Findings:  Three physician reviewers found that in this clinical situation, the requested vertebral fracture assessment (CPT 77082) is not likely to be superior over other tools for evaluating this patient.  This patient has been prescribed calcium and Vitamin D supplementation in addition to an appropriate oral bisphosphonate.  She developed gastrointestinal intolerance to the oral bisphosphonate, and she was started on intravenous Reclast.  This patient has been diagnosed with osteopenia, and it has not been demonstrated that vertebral fracture assessment will add to her medical management, as she is currently on the appropriate medical therapy.  The testing at issue is not likely to be of greater benefit than the gold standard, lateral spine x-rays.  Thus, the requested testing is not likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds with accessories. Findings: The records provided for review document that this patient has a history of paraplegia with at least good strength in the upper limbs. The patient has requested a power wheelchair. In the setting of neurologically-based mobility impairments, means of mobility should focus on more active means for the purposes of general health promotion. Moreover, manual wheelchairs provide greater maneuverability, particularly in indoor environments, due to their smaller size, smaller turning radii, and more direct control of the device. This patients records do not report any impairments of the upper limbs to preclude use of an optimally fitted manual wheelchair to accomplish mobility-related activities of daily living. The records do not indicate whether the manual wheelchair being propelled by staff is designed for efficient self-propulsion with design elements such as an optimally placed axle. All told, the requested power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds with accessories is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 37-year-old woman who has had cystic acne for several years. Topical acne medications, oral minocycline, and orthotricyclen have been prescribed by the patients primary care physician with variable results. The patients primary care physician has requested a referral to a dermatologist, which has been denied by the Health Plan.Analysis and Findings:Inflammatory acne vulgaris and cystic acne vulgaris are medical conditions, which can lead to significant to severe disfigurement secondary to scarring. Dermatologists are experts in treating cystic acne vulgaris. After attempting treatment of the patients cystic acne the patients primary care physician recommended the patient consult with a dermatologist. As such, it is medically necessary to refer the patient to a dermatologist for assistance in treating this potentially debilitating medical condition. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy sessions for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of patients with depression.  In this patients case, the medical records document an acute major depressive episode that was causing significant functional impairment.  She had failed multiple medication trials and had pursued other standard therapies.  There is sufficient support in the current medical literature for the services at issue.  All told, TMS therapy sessions provided from the time frame specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested intravenous immune globulin (IVIG) for medical treatment of her antibody deficiency. Findings:  The physician reviewer found that a trial of prophylactic antibiotics is typical of the treatment of specific antibody deficiency (Orange, et al). However, this patients disease appears to be more severe. As such, there is evidence specific antibody deficiency, for which IVIG is one of the medically accepted treatment options (Orange, et al). Although there are no randomized control studies, several smaller studies have demonstrated benefit (Zora, et al). For these reasons, the requested IVIG is medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. The first step in the evaluation of a palpable mass is imaging, which then determines the need for biopsy to rule out cancer. Per the American College of Radiology (ACR), Ultrasound should be the first imaging study in a patient younger than 30 who presents with a palpable mass. This patient presented to her provider with a palpable left breast mass. The provider noted that the patient also has an extensive family history of cancer. Consistent with the ACR recommendations, the ultrasound of the left breast performed in September of 2020 was appropriately chosen as the first imaging modality for evaluation. The ultrasound performed in September of 2020 was indicated to prevent serious deterioration of the patients health resulting from unforeseen illness for which treatment could not have been delayed until the patient returned to the plans service area. Given these findings, the left breast ultrasound performed was provided for evaluation and treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the services at issue were urgent care services as defined by California law. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in surgical oncology 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.