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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Dupixent, (2) Millipred, and (3) Vimpat (lacosamide). Findings:  The physician reviewer found that Seidman and colleagues reported that the addition of dupilumab to the treatment regimen of a patient with refractory bullous pemphigoid resulted in the patients symptoms of pruritus and blistering becoming well-controlled. In this case, the patient has a history of bullous pemphigoid and symptoms of chronic rash for over five years. She has been treated with oral and topical steroids, light box, antihistamines, and multiple medications including gabapentin, dapsone, and prednisone without improvement. Given that the patient has tried and failed multiple therapies, Dupixent is medically indicated as a reasonable next step. Therefore, Dupixent is medically necessary for the treatment of this patient. The records indicated that the patient was being treated for small fiber neuropathy. Given that she had tried and failed lamotrigrine and was on cabemezapine, Vimpat (lacosamide) is medically indicated. Therefore, Vimpat (lacosamide) is medically necessary for the treatment of this patient. Current medical literature does not support the use of Millipred for atopic dermatitis and pruritis. Therefore, Millipred is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications are partially 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 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 Harvoni for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a medical condition that can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 physician 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: Overturned

A 53-year-old male enrollee has requested for a referral to a dermatologist for evaluation of his scalp lesions.   Findings:  The physician reviewer found that per the Milliman Care Guidelines, treatment of actinic keratoses, lesions that are large or in high risk areas, including the head, should be referred to a dermatologist. Specifically, Brantsch and colleagues noted that there are squamous cell carcinomas that exhibit risk factors for metastasis based upon growth pattern, location on the skin, and tumor depth. Because of this, lesions that are suspicious for squamous cell carcinoma should be treated by a dermatologist who is trained in the treatment of all cutaneous malignancies. As such, the requested referral to a dermatologist for further care of this patients scalp lesion has been demonstrated to be medically necessary and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 137 hours per month of applied behavior analysis (ABA) one-to-one, 11 hours per month of supervision by a board certified behavior analyst (BCBA) and six hours per month of caregiver training. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Per the medical literature, the correlation between treatment outcomes and treatment intensity is well-documented.  Studies noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated.  In this article, 726 children (ages 1.5 to 12) were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment.  In this patients case, he appears to have made progress in many areas over the last several years, but continues to demonstrate impairment in several areas including agitation, negative vocalizations, perseverations, and stereotypy.  These persistent struggles are making it increasingly difficult for him to be successful in more generalized environments.  The medical evidence supports the requested services in this patients case.  All told, the requested 137 hours per month of ABA one-to-one, 11 hours per month of supervision by board certified behavior analyst (BCBA) and six hours per month of caregiver training 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. The fixed-dose combination ledipasvir-sofosbuvir (Harvoni) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. The treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. According to the literature, treatment duration of 8 weeks can be considered in treatment-naive patients, without cirrhosis, who have a baseline HCV RNA level less than 6 million IU/mL based on post-hoc analysis of the clinical data from the ION-3 trial. Therefore, the patient should be approved for Harvoni to prevent further development and progression of fibrosis due to ongoing HCV infection and to avoid potential complications of advanced liver disease. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for Norditropin FlexPro. U.S. Food and Drug Administration (FDA) approved indications for the use of Norditropin (somatropin) in pediatric patients include, but are not limited to, growth hormone deficiency. Deodati and Cianfarani note that growth hormone therapy in children with ISS seems to be effective in partially reducing the deficit in height as adults. In this case, the patient has been diagnosed with ISS and began treatment with growth hormone therapy at age five. He met FDA approved indications for the initiation of somatropin therapy due to suspected growth hormone deficiency. The records show the patient has nearly attained a normal adult height. The provider recommends continuing Norditropin for the next six to twelve months as his growth plates close. Therefore, Norditropin FlexPro was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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: Upheld

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for wet wipes. In a study of 54 personal hygienic wet wipes, Aschenbeck and Warshaw found a total of 132 ingredients were identified. The authors concluded that there are many potential allergens in personal hygiene wet wipes, especially fragrance and preservatives. In this case, the patient has a history of incontinence, autism, eczema, and peanut allergy. While wet wipes may represent an easy means of cleaning, they may also be exacerbating his eczema and fungal infections. Given that current medical literature identifies wet wipes as a significant source of allergen with resultant contact dermatitis in susceptible individuals, the requested supplies are not medically indicated. Therefore, wet wipes are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male has requested Nuvigil 250 mg tablet for treatment of his fatigue status post multiple severe head injuries.   Findings:  The physician reviewer found that based on review of the available records, this patient has sustained multiple prior head injuries, with residual fatigue, mood disturbance, frontal lobe dysfunction, and migraines. Nuvigil has been prescribed for the patients fatigue. Nuvigil and modafinil (Provigil) are FDA approved for narcolepsy, shift-work sleep disorder and obstructive sleep apnea with residual excessive sleepiness. A variety of studies in the literature show that Nuvigil can be beneficial for management of symptoms of fatigue post traumatic brain injury (TBI), as well as reducing depression in patients with mood disorders. One study on patients with TBI reported that excessive daytime sleepiness and fatigue are common symptoms, but noted that there is no specific treatment for affected patients (Kaiser, et al). The authors concluded that, the ability to stay awake on the maintenance of wakefulness test improved only in the modafinil group. Overall, Nuvigil has been shown to be beneficial in conditions beyond the FDA labeled indications, including this patients fatigue related to previous TBI. All told, the requested Nuvigil is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested occupational therapy for the treatment of the enrollees pervasive developmental disorder and Aspergers syndrome. Findings:  The physician reviewer found that the literature examines the effectiveness of occupational therapy on developmentally disabled children.  Schaaf and colleagues reported the effectiveness of sensory integration techniques by occupational therapists in children similar to this patient. Miller and colleagues reported a controlled study demonstrating the efficacy of occupational therapy in this population. Additionally, although the report of Roberts and colleagues was a single case study, it documented a dramatic improvement in behavior and attention with occupational therapy. This patient has had significant documentation of his motor and sensory integration problems on at least three evaluations. He also has had reported improvement by his pediatrician and his occupational therapist. Continued occupational therapy is medically appropriate and indicated for this patient. He has previously benefitted from the therapy and is likely to experience additional functional gains from continued therapy. The patient should receive one hour per week of occupational therapy for a six-month period with re-assessment at that time to determine the need for continued therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for compounded suppositories with Baclofen 4 mg and diazepam 5 mg. The documentation reviewed supports that this patient presents with chronic pelvic pain. She has been under the care of a pain specialist who recommended a compounded vaginal suppository medication of Baclofen and diazepam. While this is not the first-line treatment in pelvic pain, the compounded vaginal suppository medication of Baclofen and diazepam is an alternative treatment that has been studied and shown to be beneficial to patients with pelvic pain. Pelvic pain patients are difficult to treat with a goal of avoiding narcotic dependence. In this case, the use of this compounded medication is providing pain relief to the patient without using narcotics. It is medically necessary to manage this patients chronic pelvic pain so that she be able to conduct activities of daily living. Therefore, the requested compounded suppositories with Baclofen 4 mg and diazepam 5 mg 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 obstetrics and gynecology 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 Saxenda. Findings: In this case, the records document that this patient has not responded well to treatment of obesity with phentermine, topiramate, and Wellbutrin. The provider noted that the patient was treated with phentermine with loss of 15 pounds but they regained the weight. The patient was subsequently treated with phentermine on two occasions with loss of 10 pounds followed by loss of three to four pounds. The patient has also been managed with a combination of Topamax and phentermine without significant weight loss. Treatment with Wellbutrin for depression resulted in weight gain. Therapeutic lifestyle changes including behavior modification, dietary restriction and increased physical activity are modalities for the treatment of patients with obesity, but weight loss is difficult to achieve and maintain. The treatment of obesity with weight loss medications can be considered when a patients body mass index (BMI) is 30 kg/m2 or greater or if the BMI is 27 or greater and with concomitant weight-related medical problems such hypertension, hyperlipidemia, glucose intolerance, diabetes mellitus, sleep apnea. One clinical study found that Saxenda resulted in a greater proportion of patients who lost at least 5-10% of their initial body weight compared to placebo. Successful weight loss involves maintenance of weight loss. The current medications approved for long-term use have been demonstrated to be effective in weight-loss maintenance, which is essential for long-term weight loss. In any patient, successful weight loss depends on treatment with medications that do not cause complications. The U.S. Food and Drug Administration (FDA) noted that treatment with Locaserin has a warning for use in patients with depression. Similarly, Contrave is not recommended for patients with depression. When this patient attempted treatment with Wellbutrin for depression, she gained weight. The patient is unlikely to respond well to Contrave, which is also contraindicated due to depression. The patient tolerated Saxenda without side effects and she lost 20 pounds, which is about 10% of their body weight. Furthermore, the patients prediabetes has resolved. Discontinuation of Saxenda is likely to result in regain of weight. Thus, long-term treatment with Saxenda is appropriate in this patient. Given these findings, the requested Saxenda 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 internal medicine with subspecialty 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: Overturned

The patient is a 54-year-old woman with a long history of depression, bipolar disorder, and post-traumatic stress disorder. She has been receiving weekly outpatient therapy from the same provider for the last two years. The patient has requested authorization for continued weekly outpatient therapy with her treating provider. The Health Plan has denied the patients request indicating that continued weekly outpatient therapy is not medically necessary for treatment of the patients behavioral health problems.Review of the submitted records indicates that the patient has clearly benefited from weekly psychotherapy. It is clear from the patients providers progress notes that his intervention has not only kept the patient out of the hospital, but has prevented self-injury. The documented pharmacotherapy seems to be of much less benefit. The patients psychiatrist also indicates that the requested therapy is clinically indicated. Clearly, discontinuation of the current frequency of therapy is likely to increase self-injurious behaviors and impair the patients level of functioning, possibly to premorbid levels. Furthermore, if therapy is discontinued it is likely to lead to rapid and significant clinical deterioration. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Weekly outpatient therapy with the patients current provider should be continued for a period of nine months with reevaluation of the patients clinical condition at that time. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 50-year-old female enrollee has requested for MRI of the lower leg for evaluation of her right knee and leg pain. Findings:  The physician reviewer found that it is not at all clear as to what exactly the requested MRI would show, since that diagnostic scan is not a mainstream test to determine whether or not there is arterial disease.