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

The patient is a 32-year old female with a history of chronic abdominal and pelvic pain secondary to endometriosis, protein c deficiency, status post bilateral deep vein thrombosis, and chronic nausea. Per the submitted documentation the patient has been evaluated by multiple pain management specialists. She has been receiving Buprenex via a PICC line with Phenergan and has related adequate pain control. She is requesting authorization and coverage for Buprenex for treatment of her chronic pain condition. The Health Plan has denied the patients request.The Health Plans denial should be upheld. There is no information in the documentation provided outlining the various medical treatments the patient has tried and/or failed. Therefore, there is insufficient evidence that Brupenex is warranted. The Health Plans formulary has multiple medication options and per the documentation provided, there is no documentation of any previous medication trials, failure, intolerance or contraindication to the present formulary alternatives. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for one hour per week for treatment of the enrollees severe articulation disorder. Findings:  The physician reviewer found that there is research that persistent articulation disorders can be improved with specialized speech therapy. Problems with articulatory phonetics can be improved with speech therapy. Colleagues reported that many persistent articulation disorders can improve spontaneously between age nine and high school, however ongoing speech therapy was recommended to mitigate any social difficulties from the errors. This patient has a severe articulation disorder with skills at the four year and six months to the five year and three months levels. This level of delay meet the criteria for speech therapy based on the information provided. Given these findings, the requested speech therapy for one hour per week is medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in developmental and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MiniMed G670 insulin pump and continuous glucose monitor hybrid closed-loop system. Findings:  The physician reviewer found that the MiniMed 670G system is U.S. Food and Drug Administration (FDA) approved for the management of type 1 diabetes mellitus in persons, 14 years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin. The MiniMed 670G System includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor (CGM) sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. Studies have showed that the closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes . This feature is of critical importance to this patient with hypoglycemia unawareness, diabetes gastroparesis and status post stroke. In addition, studies also demonstrate the deleterious effect of wide glucose fluctuations as a factor in the development of diabetes related complications. In this case, the patient has neuropathy, so it is important to bring the paitents hemoglobin A1c (HbA1c) to 7% with no hypoglycemia. The MiniMed 670G is a closed-loop system insulin pump with CGM that will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. With this system, the patient will be able to keep HbA1c closer to goal and while minimizing hypoglycemic and hyperglycemic events. For the reasons provided, the request for MiniMed G670 insulin pump and CGM hybrid closed-loop system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested device is likely to be more beneficial for treatment of your medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested a vertical auto profile (VAP) cholesterol profile for evaluation of her dyslipidemia. Findings:  Three physician reviewers found that according to the current scientific data and publications, the measurement of lipid subclasses with the VAP test has not been demonstrated to have incremental benefit in risk stratification in patients with low cardiometabolic risk, such as this patient. In a prospective study reported by Mora and colleagues, the authors concluded that cardiovascular risk prediction associated with lipoprotein profiles were not superior to standard evaluation. Moreover, the consensus statement by Brunzell and colleagues on lipoprotein management in patients with cardiometabolic risk, determined that lipoprotein subclass measurement was not of additional clinical benefit beyond conventional diagnostic testing with HDL analysis. For these reasons, the VAP testing performed in this patients work-up was not likely to provide any supplementary valuable information helpful in her diagnosis and treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old woman who has been treated for psoriasis with Raptiva with beneficial results. Prior treatment with topicals and UVA was unsuccessful. Methotrexate and cyclosporin are contraindicatd because of a family history of pulmonary fibrosis. The patient recently changed health insurance plans and Raptiva is not a formulary medication under her current plan. The Health Plan will authorize Enbrel for the patient. The patient is concerned about the side effects of Enbrel and therefore wishes to continue treatment with Raptiva.  Review of the relevant medical literature does not demonstrate that Raptiva is safer than Enbrel or carries a lower risk of side effects.  According to the Food and Drug Administration approval, Raptivas side effects include: immune hemolytic anemia, immune thrombocytopenic purpura, arthritis, and worsening of psoriasis (sometimes to the point of hospitalization for generalized erythroderma).With both Raptiva and Enbrel there may be an increase in serious infections, a theoretical increased risk of malignancy, rare occurrence of demyelinating disorder, new onset or exacerbation of seizure disorder, and rare occurrence of tuberculosis (TB). A TB skin test is essential prior to the use of either drug. Only Raptiva treatment requires frequent testing for platelet counts.Because scientific evidence demonstrates that Enbrel is a medically reasonable and appropriate alternative to Raptiva, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the MyRisk Genetic Panel (81479) for evaluation of the enrollee, who has a history of breast cancer.  Three physician reviewers found that in this patients case, a portion of the services at issue was likely to have been of greater benefit than other alternatives.  Screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  This patient has a history of invasive ductal breast cancer, and as such is eligible for coverage for BRCA1 and BRCA2 testing.  However, the other genetic tests included in the MyRisk Genetic Panel were not indicated in this clinical setting.  Final Result: Three reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be partially overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Balversa (erdafitinib) 4 mg tablet, two (2) tablets daily. The National Comprehensive Cancer Network recommends surgical debulking with adjunctive therapy, including bevacizumab or olaparib or niraparib, as primary treatment. Balversa is not included in the recommended adjunctive regimens.  Balversa is not approved by the U.S. Food and Drug Administration for the treatment of ovarian and fallopian tube cancers. The major drug compendia and medical literature do not support the use of Balversa for the treatment of fallopian tube cancer. In this case, this treatment is not considered a standard of care. Therefore, Balversa (erdafitinib) 4 mg tablet, two (2) tablets daily 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 in medical 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that 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. For this reason, the digital breast tomosynthesis performed on 8/1/16 was likely to be more beneficial for evaluation of the patients breast exam than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure 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 physician 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.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested residential level of care or partial hospitalization program level of care for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that the data reviewed do not support the medical necessity for residential level of care or partial hospitalization program level of care.  Per the submitted documentation, the patient has continued to gain weight and shows no additional comorbidity.  Recent laboratory values show no significant abnormalities, and her vital signs are within normal limits. On the said date, the patients weight was greater than 80% of ideal body weight. The patient has been participating regularly in the program, and she shows no indication of suicidal or homicidal ideation. She does not appear to need daily medical monitoring. In this patients case, the requested services are not medically necessary per current evidence-based standard practices and expert consensus as set forth in American Psychiatric Association guidelines. All told, the requested resumption of residential level of care or partial hospitalization program level of care is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested a nephrectomy within the requested timeframe for treatment of renal carcinoma.  Findings:  The physician reviewer found that despite the assertions by the oncologists and the radiologist as to the urgency of this disease, there is absolutely no evidence that delaying the operation will have any adverse affect on either the conduct of the procedure or the cancer outcome.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacral nerve stimulation testing. According to the American Urological Association (AUA) guidelines, sacral nerve stimulation is considered an appropriate salvage therapy for patient with intractable irritative lower urinary tract symptoms including frequency and urgency incontinence. Sacral nerve stimulation is performed as a tertiary salvage procedure. With regard to this patient, there is no documentation demonstrating the patient has tried and failed first- and second-line treatment modalities for his irritative urinary tract symptoms. The provider noted the patient failed Myrbetriq. However, primary and secondary treatment options include bladder training, physical therapy, biofeedback, and medications. Prior to sacral stimulation therapy, the patient should be considered for second-line treatment options and modified pharmacotherapy. For these reasons, the requested sacral nerve stimulation testing is not supported as medically necessary for evaluation of this patients irritative lower urinary tract symptoms.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for posterior cervical fusion stabilization surgery. The records indicate that this patient presents with chronic neck pain. She has a neurological examination that has been within normal limits. She has no localizing features to her pain to implicate any level of her cervical spine as her pain generator. She has no dermatomal/myotomal symptoms or findings of a cervical radiculopathy. Moreover, the patient has no symptoms of spasticity, increased tone, or pathologic reflexes. There is no evidence of cervical instability. The patients symptoms of increased pain with use of arms above her head and with subclavian bruits suggest that subclavian steal and other vascular problems need to be ruled out. Moreover, there is no documentation of failed conservative management or that the patients pain affects her ability to perform activities of daily living. Overall, the criteria for posterior spinal fusion from the North American Spine Society have not been met in this patients case. The patients symptoms and findings are not consistent with cervical radiculopathy/myelopathy and there is inadequate documentation of failure of conservative management. Thus, the requested posterior cervical fusion stabilization surgery is not supported as medically necessary for treatment of this 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 neurological 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was noted to be experiencing post-acute withdrawal symptoms in the form of sleep disturbance, anxiety, and nightmares. However, these symptoms are consistent with a diagnosis of PTSD. The patient was not a danger to herself or others. She was medically and psychiatrically stable. There were no documented emotional, behavioral, or cognitive issues that would preclude her from continuing her recovery at a lower level of care. She was motivated for relapse prevention. Her recovery environment in terms of her relationships with family, was not conducive for her overall well-being. However, she was seeking sober living which would be supportive and not undermining to her recovery. Although she continued to struggle with her emotions and required further treatment to help her develop coping skills, she no longer required 24-hour monitoring in the residential setting. Therefore, the requested residential treatment center services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 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 patient has been diagnosed with atopic dermatitis, and is requesting authorization and coverage for a Dupixent 300 mg/2 mL syringe. Findings: Medical literature reported, for all patients, basic management and flare prevention consists of daily showers or baths followed immediately by the application of emollients and moisturizers, with avoidance of triggers such as irritants, aero- or food allergens, and extremes of heat, cold, or humidity. In mild AD, treatment involves as-needed use of low- to mid-potency topical corticosteroids (TCS); in moderate- to-severe AD, a mid-potency TCS should be regularly used. Topical calcineurin inhibitors (TCI) (pimecrolimus or tacrolimus) and crisaborole are U.S. Food and Drug Administration (FDA)-approved alternatives. The study also noted, Chronic or recurrent use of systemic corticosteroids is not recommended, but these medications may serve as bridge therapies to more appropriate, long-term treatment. In this case, the patient has been treated with topical steroids, a calcineurin inhibitor, and antibiotics for secondary infection. The patient has changed their skin care routine regarding moisturizers and laundry detergent. The patient has not maximized their topical steroid therapy, nor have they been tried on a short course of oral steroids. A trial of topical steroids, class I, in addition to consideration of a short prednisone taper would be recommended prior to initiation of Dupixent therapy. The medical evidence does not support the requested medication in this clinical setting. Therefore, a Dupixent 300 mg/2 mL syringe 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 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.