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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 100 mg per week of testosterone cypionate (Depo-testosterone) and if not 75 mg per week. Findings:  The physician reviewer found that there is support in the medical literature for a portion of the requested medication dosage in this clinical setting. Specifically, testosterone cypionate (Depo-testosterone) is medically necessary. In 2016, the patient was noted to have an elevated hematocrit. However, it is unclear if this was calculated using the male reference range values. Based on the male reference range values, his hematocrit could be considered within the normal range. The standard typical doses for transgender or cisgender male with regards to testosterone intramuscular is 100 mg a week. Measuring testosterone level can be difficult as there are wide ranges and the peak and nadir levels. Typical normal values of testosterone is between 32 ng/dL through 1000 ng/dL. The patient states that in the past when he took a higher does, he felt better emotionally and had less abdominal cramping. As such, the patient can start at 75 mg per week. Part of transgender treatment is individualizing care based on patients goals in the context of informed consent as to the risks and benefits. The standard practice is to take into account the individuals moods, the desire for virilization, fertility concerns as well as other concerns. The medical literature and guidelines supports trying higher doses to observe its affect on mood and/or abdominal cramping. Therefore, it has been demonstrated that 75 mg per week of testosterone cyplonate (Depo-testosterone) is medically necessary.Final Result: The reviewer determined that a portion of the requested medication dosage 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 morphine 300 mg per day for treatment of the enrollees retroperitoneal fibrosis.  Findings: The physician reviewer found that the patients records suggest that tolerance has taken place since the start of treatment with narcotics (Chen, et al). Adding more pure mu agonists will only improve the patients symptoms of mu agonist saturation for a short while. However, down regulation will transpire and then the patient would again experience his initial perception of pain. In addition, the patients records do not demonstrate that all non-opioid treatment options have been utilized including behavior therapy (Lee, et al). Consistent with these findings, the requested morphine 300 mg per day is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition.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: The patient has requested authorization and coverage for peripherally inserted central catheter (PICC). A PICC line is a peripherally inserted central catheter that is indicated for use for patients with inadequate peripheral venous access, or those who are receiving long-term intermittent or continuous administration of medications such as chemotherapy or parenteral nutrition. There are several complications from the use of a PICC line including serious infections and blood clots around the catheter. In this case, the patient is capable of tolerating oral fluid and food but notes he is only able to tolerate one cup of fluid a day. A PICC line is not indicated for ongoing hydration on an intermittent basis. The patient is requesting placement of a PICC line for weekly IV fluids of one liter to prevent kidney stones and maintain hydration. The risks for potentially life-threatening complications outweigh the benefit of receiving a liter of IV fluids a week. If supplemental hydration is required, an alternative method should be investigated. The requested PICC is not medically necessary for the patients medical condition.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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Regranex topical gel for treatment of his medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with ulceration to the plantar aspect of the right second metatarsal head. Regranex gel is indicated for the treatment of diabetic ulcerations. The highlights of prescribing information states that the efficacy of Regranex has not been established for pressure ulcerations, which this patient has. As Regranex does not have a documented indication for the treatment of pressure ulcerations, the medication has not been established as 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 podiatry 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 Epclusa and ribavirin for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment.  The guidelines recommend Epclusa and ribavirin for 12 weeks as first-line therapy for genotype 3 patients with decompensated cirrhosis (or patients with Childs-Pugh Class B), regardless of prior therapy. Final Result: The reviewers determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an 11-year-old female enrollee has requested  for acupuncture treatments for treatment of the enrollees eczema.  Findings:  Three physician reviewers found that the standard of care of eczema is topical steroids and non-steroidal anti-inflammatory agents such as pimecrolimus. Other conventional options include non-prescription measures such as the use of moisturizer, gentle soap, and fragrance free detergent. All patients with eczema should also be evaluated by a dermatologist. Pfab and colleagues suggest that acupuncture may be helpful in eczema, however, large scale, double-blinded, placebo-controlled studies are currently lacking. Since the available data is anecdotal at best and inadequate to establish the safety and effectiveness of acupuncture as a treatment modality for atopic dermatitis or eczema, the therapy remains investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for a partial liver lobectomy at a tertiary care center for the treatment of the enrollees hepatic cyst. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue. This patient requires an expert, hepatobiliary-trained surgeon.  Her tumor is a rare tumor, and complete surgical resection is appropriate. Her case is complicated by previous unroofing. Hopefully, this will not be an issue but does create scarring/adhesions which make subsequent resection difficult. Additionally, although the pathology appears benign, what was left behind may not be.  In this patients case, the anatomy makes the surgery challenging.  Her provider has noted that the patient may need portal vein embolization.  Per the records, the patient has a central lesion which will likely require extended resection.  This may be an intraoperative decision based on the ability to preserve blood supply and parenchyma.  Trisegmentectomies are very high-risk procedures, and the hospital support structure must be set up to handle all aspects of her care. The current medical evidence supports the requested services in this patients case. All told, the requested partial liver lobectomy at a tertiary care center 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg injections every four (4) weeks. Current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara is different than that of anti-TNF medications and Entyvio, both of which this patient has failed. A study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple other studies have shown that dosing intensification (to 90 mg every four weeks) was used frequently to address loss of response, and a large portion of patients were able to maintain response. Additionally, in this case, alternative therapies are limited, as all other biologic therapies for Crohns disease have failed. For these reasons, Stelara 90 mg every four weeks is supported as medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested medication Lexapro for treatment of depression.  Findings:  The physician reviewer found that there is no evidence that the patient has ever received a trial of any other antidepressant. Based on the information provided, there is no reason to believe that she would not respond as favorably to any other SSRI, such as Celexa. Thus, it has not been established that Lexapro is superior to other SSRIs for treatment of this patients depression.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a second Urolift procedure. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has a history of benign prostatic hyperplasia previously treated with Urolift procedure. His prostatic urethra was noted to be open after the procedure. He continues to have symptoms.  The patients provider has recommended an evaluation, including cystoscopy, which the patient has not performed.  Without performing a repeat cystoscopy, it would not be possible to determine if his prostatic urethra is open or closed.  All told, the requested second Urolift procedure is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 80 units subcutaneously twice a week. The U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel for the indication of nephrotic syndrome. Medical literatures report that Acthar Gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this clinical setting, the requested medication is medically indicated. Therefore, Acthar Gel 80 units subcutaneously twice a week 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 internal medicine with sub-specialty certification in nephrology 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 63-year-old female enrollee requested percutaneous tibial nerve stimulation (PTNS) for medical treatment of her urinary frequency.  Findings:  Two physician reviewers found that further evaluation with urodynamics, bladder diary and post-void residuals are indicated prior to considering percutaneous tibial nerve stimulation. Moreover, the patient has an underlying neurological disorder that causes ataxia and mobility problems and it is unlikely that treatment with PTNS will be beneficial unless these issues are treated and addressed first. Therefore the requested services are not likely to be more beneficial than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 28-year-old male who had a cerebral hemorrhage due to a ruptured AVM at the age eight years, which left him with a left hemiplegia. He has been receiving Botox injections since 1995 for left upper extremity spasticity, with a positive outcome. The patient continues to have left arm and hand spasticity and has requested authorization for continued Botox therapy. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The patient has a 10-year record of improvement in his splasticity with the application of Botox injections. With established efficacy, Botox therapy is the standard of care for the treatment of upper extremity splasticity and is a covered Medicare benefit. The Health Plan recognizes that Botox may be medically indicated for the treatment of spastic hemiplegia due to hereditary, degenerative or demylinating diseases of the central nervous system and the plan specifically covers Botox injections for the treatment of  spastic hemiparesis that occurs with cerebral palsy. Spastic hemiparesis related to intracranial hemorrhage in a child is not substantially different from those conditions for which the medical necessity of Botox injections is acknowledged by the Health Plan.  The treatment has clearly provided a benefit and continued treatment is consistent with the standard of care within the neurological community. As such, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a mastopexy with breast reduction surgery for treatment of her symptomatic breast implants.  Findings:  The physician reviewer found that the patient had undergone breast augmentation and mastopexy previously. The patients preoperative bra cup size was reported to be DD, and reportedly is G at this time.  She now has evidence of symptomatic bilateral macromastia secondary to large breast implants. She reported neck and back pain last year.  The functional goal of relieving symptoms could be achieved with removal of the patients current implants. Thus, although explantation is medically indicated in this case, the requested mastopexy is not medically necessary for this patient. Additionally, the patients medical condition does not constitute an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. All told, the requested mastopexy with breast reduction surgery is not reconstructive in nature and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ofatumumab (Kesimpta) subcutaneous auto-injector 20 mg/0.4 mL every four weeks. The records provided for review document that this patient has a diagnosis of relapsing-remitting multiple sclerosis with active disease in the spinal cord. The patients provider has recommended treatment with Kesimpta, which is a disease-modifying therapy. The American Academy of Neurology (AAN) guidelines, as well as multiple studies, have shown the benefit of disease-modifying therapies to decrease relapses and reduce magnetic resonance imaging (MRI) activity in patients who have experienced relapses and/or MRI activity. The U.S. Food and Drug Administration (FDA) has approved Kesimpta for the treatment of patients with relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. Per the AAN recommendations for the treatment of patients with multiple sclerosis, this patient meets the criteria for treatment with disease-modifying therapy (Rae-Grant, et al.). In addition, the requested for treatment with Kesimpta is supported by the peer-reviewed medical literature. Olek and colleagues noted that monoclonal antibodies for the treatment of patients with multiple sclerosis may be preferred for patients with more active disease, as in this patients case. Hauser and colleagues concluded that Kesimpta was associated with lower annualized relapse rates that treatment with teriflunomide. Given these findings, the requested ofatumumab (Kesimpta) subcutaneous auto-injector 20 mg/0.4 mL every four weeks is medically necessary for 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 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: Upheld

A 57-year-old female enrollee has requested a consultation regarding lap band surgery for an evaluation of her obesity. Findings:  The physician reviewer found that the patient does not meet the criteria set by the National Institutes of Health (NIH) consensus statement for bariatric surgery. It has not been sufficiently established that the patient has the co-morbidity criteria that would require such surgery combined with her BMI of 38. There are discrepancies in the record regarding whether the patient has obstructive sleep apnea. Although one submitted criteria checklist for bariatric surgery candidates notes that the patient has a co-morbidity (among others) of moderate obstructive sleep apnea, a copy of that checklist does not have the co-morbidity of sleep apnea checked. In addition, there is no documentation of a diagnosis of sleep apnea anywhere in the records provided. Finally, the surgical peer-reviewed literature lacks studies in support of preventive weight loss surgery, and there are no established guidelines to support the necessity of weight loss surgery to combat existing or potential co-morbid conditions that are non-severe.