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

Nature of Statutory Criteria/Case Summary: The patient is a 13-month-old male who has been diagnosed with atopic dermatitis. The patient was noted to have intermittent itching. Physical examination findings included a healing right cheek excoriation and faint erythematous scaly thin plaques. A xerotic patch was noted on the patients left leg. The patient was noted to have a history of eczema and has been treated with Elidel topical cream, fluocinolone, hydrocortisone, mupirocin, and triamcinolone. The patients parent has requested authorization and coverage for tacrolimus (Protopic) 0.03% ointment. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus (Protopic) 0.03% ointment is medically necessary for the treatment of the patients medical 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. Eichenfield and colleagues reported, Tacrolimus 0.03% ointment and pimecrolimus cream are indicated for use in individuals age two years and older, while tacrolimus 0.1% strength is only approved in those over age 15 years. However, evidence from clinical trials supports the safe and effective use of topical tacrolimus 0.03% and pimecrolimus in children less than 2 years of age, including in infants. In this case, the patient is a 13-month-old with atopic dermatitis and a history of eczema. Per the records, he has tried multiple medications. The medical evidence supports the requested medication in this clinical setting. The use of tacrolimus will have a steroid sparing effect that will help to decrease long-term unwanted effects of steroids, including striae and thinning of the skin as well as potential systemic effects, including stunted growth.  In this patients case, the requested medication is medically necessary to prevent disease, disability, and other health conditions or their progression. Therefore, tacrolimus (Protopic) 0.03% ointment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins in her right leg.   Findings:  Three physician reviewers found that the appropriate role for sclerotherapy is limited to the treatment of recurrent varicose veins following surgery and thread veins. There is inadequate scientific data establishing the superiority of sclerotherapy in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Enbrel for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The Health Plan appropriately requires a Psoriasis Area Severity Index (PASI) score of greater than 10 to indicate the presence of moderate to severe psoriasis.  This information was not contained within the medical record.  Therefore, the requested medication Enbrel 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 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: Upheld

A 25-year-old female enrollee has requested outpatient psychotherapy twice per week for treatment of her anxiety disorder and depression. Findings:  The physician reviewer found that based on the records provided, the twice weekly treatment plan was not clinically indicated by the current American Psychiatric Association (APA) practice guidelines. As noted by the APA, the role of psychodynamic psychotherapy is limited and is recommended for about 12 weeks. In addition, the treatment of anxiety disorders has a wide array of pharmacotherapy options, which were not described in this patients records. Finally, this patients primary diagnosis is inconsistent as panic various diagnoses have been mentioned including disorder, generalized anxiety disorder, obsessive compulsive disorder, and major depression. Management of her complex condition would require different approaches and may lead to ambiguous therapeutic interventions. As this patient still has a litany of pharmacotherapeutic options available for management her condition, the medical necessity of the twice weekly psychotherapy sessions has not been established in this instance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for olopatadine HCL eye drops. Findings: Based on the records provided for review, this patient presents with eye symptoms of burning, itching and drainage. The patient has a history of bilateral conjunctivitis as well as rhinitis. Although treatment with olopatadine is indicated for this patients condition, there are several standard alternatives available for treatment. Medical studies demonstrate equivalence of many of these medications with olopatadine. There is a lack of support in the medical records that the patient experienced adverse reactions to multiple medications and therefore is a good candidate for treatment with one of the other formulations. For these reasons, the requested olopatadine HCL eye drops are not medically necessary for this patient. Final Result: The reviewer determined that the requested services medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in ophthalmology 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: The parent of an enrollee has requested reimbursement for the GeneSight Psychotropic test for evaluation of the enrollees autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). Findings:  2/3 of the physician reviewers found that clinical trials showing the efficacy of psychotropic testing in improving health outcomes have not been completed. Moreover, documentation that the standard of care for medication management of ADHD was not provided for this patient and there is a lack of data that deviating from standard of care to provide genetic testing to identify alternative medications was appropriate. Given that there is no documentation of the patient being treated with any stimulant medication for ADHD or one from each major class prior to attempting Strattera or alpha 2 agonists, there is inadequate clinical justification based on substantial medical research to support genetic screening tests in this clinical setting. All told, the GeneSight Psychotropic test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in psychiatry with sub-specialty certification in child and adolescent 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.Physician reviewer number two is board certified in psychiatry with sub-specialty certification in child and adolescent 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.Physician reviewer number three is board certified in psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 59-year-old female enrollee has requested authorization and coverage for a 28 day supply of Peg-Intron, 80mcg/0.5mL pen injections (quantity of 4), maintenance therapy for treatment of the enrollees hepatitis C status post liver and kidney transplant.  Findings:  The physician reviewer found that the patient has already had a failed liver transplant due to a fast recurrence of hepatitis C. Should the patients hepatitis progress to cause end-stage liver disease, the patient will likely not be considered a candidate for a third liver transplant. The Health Plan points to the HALT-C trial as evidence that Peg-Intron maintenance therapy is not effective in this setting. However, this study did not include post-transplant patients. Previous research on non-transplant patients has not been validated as a predictor of a lack of response to maintenance therapy in post-transplant patients (Kornberg, et al. 2007). There have been many independent, smaller scale studies that have demonstrated that post-transplant patients who show evidence of biochemical response have less fibrotic progression. Less fibrotic progression has been linked to graft longevity and patient longevity (Singh, et al.). This treatment regimen has been shown to be effective in preserving this patients liver function. Therefore, the requested medication is medically necessary and the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the evaluation of her breast examination. Findings:  Two physician reviewers found that current studies support the addition of digital breast tomosynthesis (DBT). The findings of these studies indicate that the use of DBT reduces false positives and increases cancer detection when compared to 2D Full Field Digital Mammography (FFDM, 2D) mammography alone. 3D allows better characterization of possible masses, spiculation, and architectural distortion. The above statement is strongly supported by data in the studies by both Skaane and colleagues and Ciatto and colleagues. In this case, the provider indicated that the patient also had additional risk factors.  For these reasons, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for the 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 radiology with sub-specialty certification 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: Upheld

A 55-year-old female enrollee has requested Beyaz for treatment of her endometriosis.  Findings:  The physician reviewer found that the medical records and medical literature were thoroughly reviewed. The patient was diagnosed with endometriosis at laparoscopy. The patient states that Gianvi gave her chest pains and this was discontinued, but Beyaz improved her symptoms within only a few days. There is documentation that she is taking estrogen replacement therapy. There is no mention of her menstrual status. However, the records suggest that she is postmenopausal given the documented estrogen replacement therapy. Based on the records provided for review, the documentation does not support the medical necessity of the requested Beyaz. All told, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested genetic testing for evaluation of her pregnancy loss.  Findings:  The physician reviewer found that this patient underwent genetic testing after the loss of a twin pregnancy conceived via in vitro fertilization. Prior to this pregnancy, she had no history of pregnancy loss. According to the Practice Committee of the American Society for Reproductive Medicine guidelines, a multiple gestation pregnancy is considered as one pregnancy. Therefore, a pregnancy with loss of both implantations is considered one pregnancy loss. It is within the standard of care to perform genetic testing of the products of conception after two or more pregnancy losses as this is the accepted definition of recurrent pregnancy loss. Current guidelines do not support the use of genetic testing of the products of conception after one pregnancy loss. As such, the genetic testing performed in this case was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested continued residential treatment services for treatment of the enrollees major depressive disorder and polysubstance dependence. Findings:  The physician reviewer found that there has been minimal progress in treatment. The patients attention deficit/hyperactivity disorder symptoms and his familys history of drug use do not appear to have been adequately addressed in the treatment plan. He lacks the necessary motivation for treatment that is required for residential treatment level of care to be effective. There is no evidence the patient is at risk to self or others. He has been in residential treatment for well over a month, and it appears unlikely that he will benefit further from this level of care. American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to be safe and effective. All told, residential treatment provided during the time period at issue and continued residential treatment services were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heart surgery to prevent stroke for treatment of the enrollees atrial septal defect (ASD). Findings:  Two physician reviewers found that based on the clinical documentation submitted for review, the request for heart surgery to prevent stroke is indicated due to the patients history of exertional dyspnea, large left to right shunt at the atrial level complicated by bi-atrial enlargement including severe left atrial enlargement. The patient has already developed bi-atrial enlargement as well as right ventricular enlargement which indicates that adverse hemodynamic consequences associated with the PFO have begun to occur. The patient has been treated with Eliquis. The medical literature review supports repair of the PFO for the prevention of further adverse and irreversible hemodynamic consequences. For the reasons provided, the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested surgery is 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: 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: Upheld

A 57-year-old female enrollee has requested for Renova 0.025% for treatment of her skin lesions.  Findings:  The physician reviewer found that the article by Gilchrest, Renova reduces fine wrinkles and skin roughness, and it produced changes histologically such as epidermal thickening, increased granular layer thickness, stratum corneum compaction and decreased melanin content. The article by Jeffes and Tang states that retinoids alone are probably not optimal immunotherapy in the treatment of actinic keratosis. The package insert for Renova indicates that it is used to reduce fine lines and wrinkles, and has not been demonstrated to have an effect on keratinocytic or melanocytic atypia. As such, there is no medical indication for the use of Renova and its use is cosmetic in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco 10 mg four times per day. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. Similarly, the Federation of State Medical Boards (FSMB) guidelines noted that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In this case, the patient was treated with Norco for chronic pain. However, the provider noted that the patient was concurrently using cannabis for nausea related to her HIV status. The patient also has a previous history of inconsistent urinalysis positive for cocaine. The provider expressed concern over the concurrent use of opioid therapy and cannabis. The provider initiated a slow opioid taper. The provider has acted in a manner consistent with the CDC and FSMB guidelines regarding chronic opioid therapy in patients who demonstrate an unfavorable risks for ongoing chronic opioid therapy. For these reasons, the requested Norco 10 mg four times per day is not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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 40-year-old female enrollee has requested Lyrica for treatment of her nummular headaches.  Findings:  The physician reviewer found the records indicate that this patient has a new daily headache. There is inadequate clinical information to determine what primary headache disorder this represents. The final diagnosis by the treating neurologist is nummular headache. This is a very specific headache type defined by a rounded or elliptical 2-4 cm area of the scalp that is painful. There is a limited literature concerning this rare headache disorder, and no studies have been done to determine the best treatment. The literature suggests that gabapentin is one of the most effective therapies for treating this condition, followed by tricyclic antidepressants. This patient was on gabapentin prior to being switched to Lyrica. However, the time period of treatment was too short of a period to determine if the drug is effective. Further, it does not appear that gabapentin was titrated to a higher and potentially more effective dose. The records also do not indicate the patient has been treated with an adequate trial of proven headache medications including indomethacin, Amitriptyline, and topiramate. All told, Lyrica is not medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for one hour of family therapy once per week in-home, one hour of individual therapy once per week in-home, one hour of gender therapy twice per month in-home, and skills trainer services five days per week in-home. The patients current providers did not document symptom severity to support these additional wraparound services. Rather, the providers recommended case management, behavior support, group therapy, and a skills trainer three days per week. Given the information available regarding the patients symptoms, the requested services are not required to meet the essential health needs of the patient. Moreover, the requested in-home services would be for the convenience of the patient. In this case, telehealth services were recommended to enable the patient to participate in services from home. There is significant literature demonstrating the efficacy of telehealth service delivery for patients with depression. All told, one hour of family therapy once per week in-home, one hour of individual therapy once per week in-home, one hour of gender therapy twice per month in-home, and skills trainer services five days per week in-home are 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 psychiatry with subspecialty certification in child and adolescent 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.