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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgeryfor treatment of the enrollees squamous cell carcinoma in situ (SCCIS). Fulfills Findings:  The physician reviewer found that the requested surgery is not medically necessary for treatment of the patients medical condition. According to the American Academy of Dermatology appropriate use criteria for treatment of non-melanoma skin cancers, Mohs surgery is indicated for certain areas of the face, for tumors which are a large size or found to have an aggressive growth pattern by pathology. In this case, the squamous cell carcinoma in situ does not meet those criteria. Standard excision or topical therapies is the standard of care for definitive therapy in this clinical setting. Therefore, Mohs surgery is not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nivolumab (Opdivo). Currently, there is a lack of data to support the long-term safety and efficacy of Opdivo in the treatment of Ewing sarcoma. One study reported a response of cabozantinib with Opdivo in renal cancer, which is a different histology than Ewings sarcoma. Guven and colleagues discussed findings suggesting a response of Ewings sarcoma to a combination of Opdivo with Taxotere. The records provided for review document that this patient has already been treated with Taxotere with progression of disease. Furthermore, the NCCN guidelines do not endorse treatment of Ewing sarcoma with Opdivo, and this indication has not been approved by the FDA. Therefore, the requested nivolumab (Opdivo) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested nivolumab (Opdivo) is not 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 medication is 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology and is 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 reimbursement for the partial hospitalization program (PHP) services for treatment of the enrollees alcohol use disorder.Findings:  The physician reviewer found that the patient had mild post-acute withdrawal symptoms. He was not a danger to himself or others. He was not manic, psychotic, agitated, or showing impulsivity. He was newly sober, having completed a detoxification protocol, after a history of alcohol use with the longest period of sobriety of three days. He consistently reported poor appetite and sleep, and problems with memory, concentration, and the ability to think, which did not improve. He also consistently reported that he had trouble accepting that he was an alcoholic. However, he diligently worked on assignments, on his relapse prevention plan, and participated in his treatment plan. Despite his CIWA of 5, given the patients excessive drinking history, lack of any sustained period of sobriety, recent altered mental status, and hospitalization. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine 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 with a body mass index (BMI) of 44 and multiple comorbid conditions. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied the request on the basis it is not medically necessary for treatment of the patients morbid obesity.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for the medication Enbrel Sureclick 50mg/ml.According to the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, the addition of a biologic DMARD, such as Enbrel, is recommended over triple therapy (i.e., addition of sulfasalazine and hydroxychloroquine) for patients taking maximally tolerated doses of methotrexate who still have uncontrolled rheumatoid arthritis with active disease symptoms.In this case, the patient has been on methotrexate since May 2015 and has required the use of additional DMARDs, Plaquenil and sulfasalazine, but has continued to have uncontrolled rheumatoid arthritis disease symptoms. As noted above, American College of Rheumatology guidelines recommend the addition of a biologic DMARD, such as Enbrel, for patients who have uncontrolled rheumatoid arthritis despite having optimized use of methotrexate. The guidelines recommend the addition of biologic DMARD therapy with a drug such as Enbrel rather than the addition of other conventional DMARDs such as Plaquenil or sulfasalazine. Accordingly, the requested medication, Enbrel Sureclick 50mg/ml, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for visual communication analysis with self-determination theory. This patient has a diagnosis of autism spectrum disorder (ASD). She is being treated with applied behavioral analysis (ABA), which is considered the standard of care for her condition. Researchers concluded that there is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD. Overall, there is a paucity of evidence in the peer-reviewed medical literature to support visual communication analysis with self-determination theory therapy for patients with ASD. For these reasons, the requested visual communication analysis with self-determination theory 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 optometry and a certified optometric vision therapist 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

The parent of a 10-year-old male enrollee has requested a gait analysis test for an evaluation of the enrollees recurrent painful toe walking. Findings:  Two physician reviewers found that gait analysis is a standard tool today to diagnose, plan therapy and treat patients with cerebral palsy. Other disorders such as rheumatoid arthritis and dementia have not been shown to be benefitted by it. Idiopathic toe walking is an unusual but not uncommon condition, often related to speech disorders and is a form of apraxia, improper development of coordinated muscle skills. This patient has undergone extensive physical therapy and casting, and had surgery. His symptoms here recurred, and the information provided by a thorough gait analysis can be crucial in planning further therapeutic interventions such as Botox injections, targeted physical therapy, orthotic design and application, and ever further surgery. Gait analysis will provide valuable information to assist with his care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Vemlidy 25 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic hepatitis B virus (HBV). The submitted documentation supports the medical necessity of the requested medication. Guidelines for the treatment of hepatitis B from an association recommends entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically appropriate. For these reasons, Vemlidy 25 mg 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 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: An enrollee has requested authorization and coverage for stem cell treatment for her multiple sclerosis (MS). Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Hematopoietic stem cell transplantation (HSCT) is well-established in the peer-reviewed literature as the most potent therapy in highly active MS, especially when used early in the course of the disease, with long-term disease free remissions beyond seven years. The study by Researchers found that Among patients with relapsing-remitting MS, nonmyeloablative hematopoietic stem cell transplantation was associated with improvement in neurological disability and other clinical outcomes. In this case, the patient has a diagnosis of MS and her in-Plan provider reports that she is progressing in her disease, at least clinically although not radiologically. Her in-Plan provider noted that HSCT has the potential to stabilize her disease course. Since the patient is progressing despite highly effective therapy, the request for stem cell treatment has been established as medically necessary in this clinical setting. 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that in managing patients with chronic hepatitis C virus, denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. Moreover, a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. For the reasons provided above, the request for a 12 week course of Harvoni is medically necessary for treatment of the patients hepatitis C virus genotype 1. Final Result: The reviewer determined that the 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 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 a new power wheelchair and accessories for treatment of her cerebral palsy spastic quadriplegia. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. According to the documentation submitted for review, a new power wheelchair is indicated given that her current chair is in disrepair. However, the requested power wheelchair (Permobil F5 Corpus - K0884) is not medically necessary. The Permobil F5 is group 4 standard power wheelchair with power elevating seat and standing feature. In this clinical setting standard group 3 power wheelchair would be sufficient to meet the patients wheelchair needs. Based on the clinical documentation submitted, a new power wheelchair and accessories are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment is 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 physical medicine and rehabilitation 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 52-year-old male with a history of hypersomnia and depression. It appears the patients treating physician is a sleep specialist. A prior sleep study revealed mild central sleep apnea, but no evidence of obstructive sleep apnea or periodic limb movements. The patients depression has been under treatment and he ultimately achieved therapeutic success with Provigil. Ritalin was found clinically ineffective. The improvement in wakefulness was estimated at 70% after a 14-day trial of Provigil. However, absent from the patients clinical history is a definite diagnosis of refractory depression. The history also includes increased hypersomnia with two antidepressant combinations previously prescribed. The patient is also taking Paxil in combination with Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.The apparent diagnosis in this case is idiopathic hypersomnia. Clinically, the patient has improved with Provigil. Idiopathic hypersomnia is recognized as a sleep disorder. The patient appears to have failed Ritalin therapy and responded successfully to Provigil. Given the patients therapeutic response and the absence of a proposed alternative, continued treatment with Provigil is medically appropriate and indicated. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old male with headaches and daytime somnolence. His provider noted an increase in the patients headaches and fatigue approximately six weeks after stopping Provigil. Elavil has been prescribed to treat the patients headaches and there is a note from the provider suggesting the patient may be taking Celexa as well. The patients provider indicates that Provigil has been prescribed to to keep (the patient) awake and more focused during the day.  The patients request for authorization of Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea, and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as he is reportedly being prescribed Provigil for excess daytime sedation without an identified etiology. The patient also notes that he has mild narcolepsy, although there is no mention of this in the providers notes and no medical test results have been provided to substantiate this claim.Review of the relevant research revealed no studies demonstrating that Provigil has been used successfully for the treatment of headaches or for the fatigue associated with Elavil. Furthermore, the records provided do not document trials with alternative agents to address the patients sedation or to control his headaches. Numerous other medications such as calcium channel blockers, beta-blockers, less sedating antidepressants, and anti-seizure medications are available to treat headaches. Many of these medications have a lower incidence of sedation. There are also other treatment modalities including sleep hygiene interventions, increased exercise, and/or dietary modifications that have not been explored. The patients continued fatigue, sleep complaints, and headaches may also be indicative of a continued mood disturbance. Finally, the potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, 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: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that there is a robust medical literature supporting the efficacy of speech therapy in this patient population (Law, et al). In addition to data supporting the efficacy of speech therapy, Goorhuis-Brouwer and Kniff found that cognitive delays did not prevent patients from benefitting from treatment. Further, Buschmann and colleagues concluded that although catch-up development is to be expected in a substantial proportion of late talkers, our data demonstrate that a general wait and see approach is not justified in young patients with language delay. Consistent with the support in the clinical studies and standards of practice, speech therapy is medically indicated for this patient with speech delay.