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

Nature of Statutory Criteria/Case Summary: An enrollee has requested butalbital for treatment of the enrollee, who has a history of chronic migraines.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Based on the current use of butalbital, the diagnosis of medication overuse headache can be established.  Her current use of butalbital is not consistent with its intended use of only as needed.  Chronic daily use of butalbital is a common cause of chronic daily headache. The current medical evidence supports withdrawal from this medication and consideration of other preventative medications.  In sum, butalbital is not medically indicated 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 120 units of hyperbaric oxygen therapy (HBOT), press full body chamber. The records provided for review document that this transgender patient underwent a body contouring procedure with grafting of 1100 cc of fat to the flanks and buttocks. Postoperative evaluation two days after the procedure showed normal postoperative healing with swelling, tenderness, and ecchymosis. There was no report of findings indicating compromised healing of the liposuction or the fat grafted areas or threatened or compromised surgical grafts. The patients provider has recommended treatment with HBOT. Fife and colleagues noted that HBOT is ineffective when it is provided to patients who could heal without it. Bassetto and colleagues stated that, HBOT is used on occasion to treat compromised flaps and grafts, where there is decreased perfusion or hypoxia, a practice supported also by the Guidelines from UHMS [Undersea and Hyperbaric Medical Society]. In addition, the authors noted that, HBOT can help maximize the viability of the compromised tissue hereby reducing the need for re-grafting or repeat flap procedures. Overall, there is a lack of peer-reviewed clinical literature documenting the benefit of HBOT in injectable fat grafting. This patient has no evidence of threatened or compromised surgical grafts, and the use of HBOT in injectable fat grafting is not supported by the medical literature. Given these findings, the requested 120 units of HBOT, press full body chamber, is not medically necessary for this patient.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 plastic 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Onabotulinumtoxin (Botox) (Codes 64615 and J0585) for chronic migraines. The medical record shows a patient with a history of chronic intractable migraines. She has had Botox injections in the past that relieved her pain. The note stated that the patient had mild headache all the time but had severe headaches twice per week.  She states Botox was beneficial.  Examination showed no distress, upper back muscle tightness, and was otherwise normal.  Diagnoses were migraine, and neck tightness.  The medication list included Sumatriptan, Percocet, Maxalt, and Nadolol.  The patient was referred for Botox injection because she had less frequency of headache when she was treated with Botox.  The medical literature supports benefit in lessening migraine headaches with Botox. For migraine, various classes of preventives can be used including botulinum toxin, with the choice of therapy tailored to the patient's risk factors and symptoms. In studies, injections of a specified dose were generally well tolerated and effective in producing significant and clinically meaningful improvements in headache symptoms, acute headache pain, medication usage, headache impact and health-related quality of life in adults with chronic migraine. More recently, the efficacy and tolerability of onabotA (Botox) over a period of 1 year has been substantiated and extended by the results of a long-term phase IV study. In conclusion, the totality of evidence from clinical trials and real-world studies indicate that onabotA (Botox) is an effective and generally well tolerated option for the prevention of chronic migraine for patients who have previously failed to respond to or are intolerant of commonly prescribed oral preventive medications. Botox was noted to provide more relief for this patient than other medications tried, including Sumatriptan, Percocet, Maxalt, and Nadolol.     Final Result: Two of the three reviewers determined that the requested service was likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is overturned.Credentials/Qualifications: Three reviewers are board certified in Neurology and are actively practicing.  All three 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara injections every four weeks. Findings:  The physician reviewer found that mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The 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 studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patients symptoms, such as recurrent abscesses, are consistent with active Crohns disease despite Stelara 90 mg every eight weeks. She has failed multiple biologic and conventional alternatives. A Stelara level of at least 4.5 ug/mL is associated with effective disease control, however in this case, the patients Stelara level was 2.4 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara injections every four weeks are medically necessary for the treatment of this patient.Final Result: The reviewer 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Aimovig Autoinjector. The records provided for review indicate that the patients condition improved with Botox treatment. Combined treatment with Botox and Aimovig provided further benefit without problematic side effects. A recent presentation for the American Headache Society (AHS) showed that in patients on Botox who were experiencing end of treatment cycle wear-down, the addition of Aimovig appeared to boost Botox efficacy and result in sustained effects in a significant proportion of patients. Cohen and colleagues reported that fremanezumab is a safe and effective add-on treatment for migraine patients being concomitantly treated with other migraine preventive medications. Thus, there is evidence in favor of combined therapy with a medication of the same class as Aimovig. Given these findings, the requested Aimovig Autoinjector  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

The parent of a three-year-old male has requested group social skills training twice per week for treatment of his autism.   Findings:  The physician reviewer found that this nearly four-year-old patient is approaching pre-school age. Enrollment in a pre-school program will require some prerequisite social skills. It is important that the patient be introduced to socializing and interacting with his peers. Myers, et al. states that a social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. Reichow and colleagues performed a Cochrane systematic review of five randomized controlled trials which when combined suggest that there is evidence that social skills group therapy can improve social competence for children with autism spectrum disorders. While the above evidence demonstrates the importance of socials skills therapy, the patient is currently receiving 20 hours per week of ABA therapy and his current ABA treatment plan includes social skills and group skills development. As such, 2 weekly sessions of group social skills therapy in addition to the patients current ABA therapy regimen of 20 hours per week of therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block injections for treatment of the enrollees occipital neuralgia. Findings:  The physician reviewer found that The documentation submitted for review demonstrates the presence of occipital neuralgia as documented by physical examination findings. However, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve block are supported for diagnostic purposes, and not for therapeutic treatment as there is no long-term benefit supported in the peer-reviewed literature. There was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. Greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Nno long-term improvement of headache of chronic migraine type with use of occipital nerve block. As such, the occipital nerve block injections provided were not likely to be more beneficial for treatment of the patients occipital neuralgia than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Credentials/Qualifications:  Physician reviewera number one, two ,and three are board certified in neurology and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether any or all of the requested facial feminization surgeries are medically necessary for the treatment of this patient. Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria and has been on cross gender hormone therapy. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. Based on the documented history of gender dysphoria and evidence of extreme mental distress due to her current gender incongruence, the medical necessity of FFS is supported. Therefore, the requested facial feminization surgeries are medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male has requested coverage for past residential treatment level of care services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with inattention, impulsivity, disobedience, and mood symptoms coupled with strained family dynamics and budding characteristics is a challenging endeavor. Clinical guidelines and patient placement criteria have been developed to assist care providers with the complex determination process. Regarding this patients case, the documentation provided fails to demonstrate that the patient could not consolidate meaningful treatment gains in a less restrictive level of care. There appears to have been no previous intensive family therapy, which is the single best intervention for a case such as this. In addition, the patient had not previously been placed in an intermediate setting such as a therapeutic boarding school, intensive outpatient program, or partial hospital program. Further, the medical records from the residential facility do not describe any behaviors, symptomatology or medication adjustments that would require treatment in a 24-hour supervised setting. Aside from the referring provider, there was no additional psychiatric evaluation. The therapy notes did not describe symptoms consistent with a mood disorder, for which there was no evidence of treatment. The psychological evaluation assigned a global assessment of functioning (GAF) at 55, and an affective disorder was not included in the multi-axial diagnosis. Thus, based on the documentation provided, relevant peer-reviewed medical literature, and current practice guidelines, the residential treatment services provided to this patient were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested Roux-en-y gastric bypass and cholecystectomy for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria set by the National Institutes of Health for surgical treatment of morbid obesity with a BMI of 47 and multiple co-morbid conditions that will likely be ameliorated or eliminated by bariatric surgery. With regard to the Health Plans contention that medical weight loss is a viable treatment option for morbid obesity, there is no scientific evidence demonstrating that structured diet and/or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best and most durable long-term outcome for the morbidly obese. However, although medically the patient meets criteria for weight loss surgery, it does not appear that she has obtained psychological clearance for the procedure. Therefore, the patient should obtain psychological clearance before weight loss surgery is authorized.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested Increlex for the treatment of the enrollees severe primary IGFD (insulin-like growth factor deficiency). Findings:  The physician reviewer found that it would appear that the L-dopa test was judged to indicate a low GH response on the basis of only one blood level after the initial one test. A second stimulation test was not done. According to the physician, there was no IGF-1 done before GH had been initiated and that level was normal according to the standards that the lab in question had been using. Since there was also no growth response to GH therapy, GH deficiency cannot be substantiated. The diagnosis of IGF-1 deficiency also appears improbable since IGF-1 levels appeared to be normal while on GH therapy yet there was no growth response. Normal to elevated GH levels were not seen. Thus, IGF-1 deficiency was not supported. There was a delayed bone age, however, suggesting a diagnosis of constitutional pubertal delay. However, after IGF-1 therapy was given, there has clearly been a growth response accompanied by an elevated IGF-1 level reported as 732ng/ml (albeit this level might have been affected by IGF-1 antibodies induced by IGF-1 therapy). The case appears most likely to be a question of constitutional delay (not IGF-1 deficiency) which may have been compounded by familial short stature (parental heights were not documented).  Therefore, IGF-1 therapy is not medically necessary in this instance.
Appeal type: Experimental/Investigational
Decision: Upheld

The representative of a deceased male enrollee has requested reimbursement for uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) testing for evaluation of the enrollees metastatic adenocarcinoma. Findings:  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other methods of evaluation.  UGT1A1 is an enzyme involved in the metabolism of CPT-11, a commonly used chemotherapeutic agent, particularly in metastatic colon cancer.  It has been proposed that certain genotypes of this enzyme are associated with increased toxicity of CPT-11, and that dose modification in these patients should be considered.  However, there is a lack of support for the services at issue at this time.  Palomaki and colleagues noted that there is a paucity of evidence to assess the benefits and risks of modifying irinotecan regimens for patients with colorectal cancer based on this genotyping.  All told, the superior efficacy of UGT1A1 genotyping has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgery, a tracheal chondroplasty/tracheal shave. Findings:  The physician reviewer found that World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested services are medically indicated. Therefore, facial feminization surgery, a tracheal chondroplasty/tracheal shave, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.  Findings:  Two physician reviewers found that according to a study, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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.