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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested growth hormones (Nutropin AQ NuSpin)for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Although the patients height is more than two standard deviations below the mean for age and gender, his growth factors are normal, and his bone age predicts an adult height that is within normal limits.  He is not known to have a morphological abnormality of his pituitary gland.  He does not have evidence of growth hormone deficiency, and his adult predicted height is not short enough to warrant growth hormone treatment on the basis of idiopathic short stature according to U.S. Food and Drug Administration (FDA) criteria. The most likely cause of his growth fall-off is delay in pubertal development, which may have been exacerbated by underlying attention deficit/hyperactivity disorder and treatment medication.  All told, the requested growth hormones (Nutropin AQ NuSpin) are 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis has been demonstrated to be of particular benefit in patients with extremely dense breast tissue.  Overall, the addition of this technique has resulted in a decrease in callbacks and increase in detection of small cancers.  Breast tomosynthesis often allows the reader to separate dense tissue from underlying mass/architectural distortion.  Therefore, the addition of breast tomosynthesis was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  Final Result: Three reviewers determined that the services at issue were 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.  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

A 37-year-old female enrollee has requested eye surgery for the treatment of her eye problems. Findings:  The physician reviewer found that the proposed surgery is a reconstructive procedure rather than cosmetic in nature. The patient has elevation of the eyeball relative to normal position. This constitutes an abnormal structure of the body. This condition occurred as the result of trauma. The proposed procedure has been recommended to create a normal appearance to the extent possible. It is anticipated that the requested surgical procedure will offer more than a minimal improvement in the patients appearance.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 60 minutes of individual speech therapy and 30 minutes of group speech therapy per week. This patients school speech evaluation shows ongoing problems with inferences and social language. In the medical literature, authors reported that it is difficult to assess pragmatic language and recommends using several tests to better determine if speech therapy is indicated. Researchers showed that assessing pragmatic language requires in vivo pragmatic language assessment as well as formalized testing. The description of this patients difficulty with inferences and social language suggests the need for ongoing speech therapy. The testing from school revealed an overall average score, but noted problems in several areas. Given these findings, this patient requires speech therapy to address pragmatic language problems two times per week. Accordingly, the requested 60 minutes of individual speech therapy and 30 minutes of group speech therapy per week is supported as 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 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 41-year-old female who had pituitary surgery in June 2004. She is complaining of abdominal weight gain and problems with memory and thinking.  She had normal prolactin, ACTH and cortisol levels and normal thyroid function tests. An insulin tolerance test was performed and hypoglycemia did not induce a rise in growth hormone levels. The patients IGF-1 level was in the low normal range on two occasions.  Therapy with Nutropin, 0.5mg daily, was begun to bring her IGF-1 level into the mid normal range.  The patients provider plans to continue therapy for approximately six months and to monitor the patients symptoms.  The patients request for reimbursement and prospective authorization and coverage of Nutropin was denied by the Health Plan citing a lack of medical necessity. The patient had pituitary surgery in 2004.  She had subsequent symptoms of abdominal weight gain and memory and cognitive difficulties. The insulin tolerance test was indicative of a growth hormone deficiency, although growth hormone stimulation testing was not performed.  The patients IGF-1 level was low normal on two occasions; there are reported cases of growth hormone deficiency with normal IGF-1 levels in the literature. In light of all of these factors, a six-month trial of Nutropin, 0.5mg daily, is medically appropriate to see if the patients symptoms resolve. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only.Final Result: Two of the three reviewers determined that the services at issue were 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: Physician reviewers number one, two, and three 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: Overturned

The patient has requested authorization and coverage for Entyvio 300 mg every 4 weeks. The patient has been diagnosed with ulcerative colitis. Medical literature states that in a prospective study of patients with Crohns disease or ulcerative colitis receiving induction therapy with vedolizumab, low trough levels of vedolizumab at week six are associated with need for additional doses (given at week 10 and then every four weeks). All patients receiving these additional doses achieved a clinical response four weeks later. In this case, the patient has tried and failed treatment with mesalamine, Uceris, prednisone, Humira, and infliximab. The patient was noted to experience breakthrough symptoms at three to four weeks after his Entyvio infusion. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Entyvio 300 mg every 4 weeks is 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mepolizumab (Nucala) 100 mg once every four weeks for 26 weeks. Findings:  The physician reviewer found that Nucala is an add-on treatment for patients with severe persistent asthma with an elevated eosinophil count. However, this patients records do not support a diagnosis of severe persistent asthma. The patients chest was clear during three consecutive office visits. The patients estimated eosinophil count was 369. In addition, the patients oxygen saturation on room air was normal. Moreover, there is no documentation of intubation and placement on mechanical ventilation, treatment in an intensive care unit (ICU) for asthma, or a thorough work-up by a pulmonologist. All told, the requested Nucala 100 mg once every four weeks for 26 weeks is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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 54-year-old male enrollee has requested an increase in quantity of Byetta for the treatment of his diabetes. Findings:  The physician reviewer found that the present endocrinologist argues that the patient is unable to control his morning fasting blood sugars with Byetta in its present formulation. The FDA has approved a daily dose of 20mcg given twice daily. She has found a novel way to extend the action of Byetta to the next morning by utilizing a continuous overnight infusion via an insulin pump. Utilizing an insulin pump to change the pharmacokinetics of the presently available preparation of Byetta is a novel, but not off-label, use of administering the medication. Assuming that the patient continues to take all three glucose lowering agents, he should be allowed to obtain at least two Byetta pens per month until the long-acting preparation of Byetta becomes commercially available. This will allow him to maintain excellent control without resorting to insulin in the short run.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L5-S1 lumbar fusion surgery. Bydon and colleagues noted a trial of conservative therapy should be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. The authors commented that these options may include physical therapy, epidural steroid injections, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Resnick and colleagues described that as a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. The records document that this patient is being treated for vertebrogenic low back pain, lumbar radiculopathy, and inflammatory spondylopathy. The provider noted that the patient presents with back, left hip, and leg pain. Physical examination revealed a mildly antalgic gait on the left, negative straight leg raise test, and normal motor examination. The patients provider has recommended L5-S1 lumbar fusion. However, the records fail to include adequate documentation of recent, reasonable, and comprehensive less invasive conservative care measures for management of this patients back pain. The available documentation does not report that any recent treatment modalities have been attempted. In addition, dynamic flexion and extension films have not been provided to potentially assess the amount of movement at the L5-S1 level. Moreover, there is a paucity of large-scale, long-term published studies demonstrating the safety and efficacy of the requested L5-S1 lumbar fusion in this patients clinical setting. Given these findings, the requested L5-S1 lumbar fusion surgery is not medically necessary for treatment of 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Botox injection for treatment of the enrollees chronic migraines. Findings:  Three physician reviewers found that recent studies show that Botox (botulinum toxin) injections are an effective, safe, and well-tolerated treatment for the prevention of headaches for patients with chronic migraine headaches. The U.S. Food and Drug Administration approved Botox in patients with adult chronic migraine who suffer headaches on 15 or more days per month for those headaches lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. But in this patients case, the submitted records have not indicated episodic migraine headaches that occur 14 days or more per month. Moreover, there is no documentation of headache frequency or symptoms in association with the headaches which support a diagnosis of chronic migraine. As such, the submitted documentation fails to demonstrate the superior efficacy of the service at issue over available standard treatment options for this patient.  Final Result:  Three reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  Two 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left atrial appendage closure with a Watchman device.Findings:  Two of the three physician reviewers found that in this patients case, the records document chronic atrial fibrillation, hypertension and a family history of stroke. She was treated with standard therapy with Xarelto and had a significant gastrointestinal bleed with persistent anemia. As a result, she has discontinued the anticoagulant, which places her at significant long-term risk of embolic stroke. The medical evidence indicates that the Watchman device provides protection from recurrent stroke in patients with significant contraindications to long-term anticoagulant therapy. There is sufficient support for the requested services in this patients case. In sum, left atrial appendage closure with a Watchman device is likely to be of greater benefit than other available treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with an orthopedic surgeon. There is sufficient support for the requested services in this patients case. A specialty referral may be appropriate if the provider is uncomfortable with the line of inquiry, with treating a particular cause of delayed recovery, or has difficulty obtaining information or agreement to a treatment plan. Consultants may participate in the patients care by analyzing the diagnostic data, ordering additional studies as needed, and formulating a treatment plan. Current evidence-based literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. This patient presents with a history of chronic right hip pain and limited range of motion. She reports difficulty with prolonged standing, squatting, and running. Right hip x-rays are reportedly negative. She has failed long-term self-directed exercise, activity modification, and over-the-counter medications. Her primary care provider has requested orthopedic referral to order advanced imaging as indicated and formulate a treatment plan. Evidence-based guidelines and peer-reviewed literature support this referral to assist in diagnosis and treatment planning. Therefore, the requested consultation with an orthopedic surgeon is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested occupational therapy for the treatment of the enrollees hypertonia secondary to prematurity. Findings:  The physician reviewer found that this patient suffers from multiple delays that affect her ability to function in an age-appropriate manner, most likely due to her history of prematurity. She has balance difficulties, gross and fine motor deficits, and sensory processing deficits. Persistence of these deficits can lead to difficulties navigating the educational system, interacting with peers, and ultimately, entering the work force and functioning in society. With its focus on developing motor planning skills, teaching self-help skills, and developing fine and gross motor skills, OT is well-suited to affect positive change in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for facial feminization surgery. The 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 had a diagnosis of gender dysphoria and the provider recommended facial feminization surgery, the service at issue was medically indicated.  Therefore, facial feminization surgery provided August of 2019 was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 with expertise in transgender health 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.