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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroscopy shoulder biceps tenodesis (CPT 29828) and open repair of rotator cuff chronic (CPT 23412) (along with approved procedures CPT codes 29826, 29827, 29823, and 23430). Findings:  The physician reviewer found that McElvany and colleagues concluded that there is a paucity of evidence that the results of rotator cuff repair surgeries provide improved health outcomes in published studies between 1980 and 2012. The authors noted that, While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. Hawi and colleagues concluded that in cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. This patient is being treated for post-traumatic left shoulder partial subscapularis tear with long head biceps subluxation/dislocation. He presented on 11/16/21 being is approximately six weeks after a motorcycle versus auto accident. The patient reports left upper arm pain and symptoms. Physical examination of the left shoulder revealed localized tenderness about the greater tuberosity, subacromial bursa and anterior bicipital groove. The patient has been approved for CPT 29826 shoulder arthroscopy, subacromial decompression, CPT 29827 arthroscopy with rotator cuff repair, 29823 shoulder arthroscopy debridement extensive, and 23430 tenodesis of long tendon of biceps. However, detailed documentation is not evident regarding the need for the surgical procedure to be performed both arthroscopically as well as open. For these reasons, the requested arthroscopy shoulder biceps tenodesis (CPT 29828) and open repair of rotator cuff chronic (CPT 23412) (along with approved procedures CPT codes 29826, 29827, 29823, and 23430) 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz.  Xeljanz has been shown to be of benefit to patients with AA. In a recent study, researchers found evidence for the effectiveness of tofacitinib in the treatment of AA. They compared the efficacy and tolerability of oral tofacitinib to conventional modalities for treating refractory alopecia. A total of 74 patients were included in the study. Of the 74 patients, 18 were treated with tofacitinib, 26 were treated with a conventional medication, and were 30 treated with another medication. After 6 months, 44.4% of patients in the tofacitinib group, 37.5% in the conventional oral treatment group, and 11.1% in the other group achieved 50% improvements in the Severity of Alopecia Tool score. It was concluded that oral tofacitinib was more effective and more tolerable than conventional oral treatment after 6 months of treatment.In this case, the patient has tried and failed other standard therapies, including steroid injections. The patient had recently started topical tofacitinib (Xeljanz) ointment with some improvement. The use of Xeljanz in this clinical situation is supported by recent medical evidence. Therefore, Xeljanz is medically necessary for 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement and prospective authorization and coverage for enhanced external counterpulsation (EECP) for treatment of the enrollee who has been diagnosed with Peyronies disease.  Findings:  The physician reviewer found that There are limited trials that note the efficacy of the services at issue. Additionally, the medical literature does not indicate if EECP therapy is safe and effective in decreasing the pain and curvature that are associated with Peyronies disease. His degree of curvature is not documented and the outcome of the therapy have not been documented. EECP is not accepted as a standard of care for the management of Peyronies disease. In recent trials, certain novel therapies have shown to be superior to EECP. Moreover, this patient does not have any trouble with intercourse. Therefore, EECP services were not and are not likely to be more efficacious than the standard methods of treating this patients medical condition. Final Result: Two of three reviewers determined that the services at issue were not and are 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

The parent of a 17-year-old female enrollee has requested  for residential substance abuse treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the RTC progress notes document that the patient was experiencing anxiety attacks. The notes indicate frequent anxiety and Lexapro was increased. The patients affect was described as appropriate with euthymic mood. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care criteria and American Academy of Child and Adolescent Psychiatry (AACAP), RTC was medically necessary given the patients significant functional impairment, history of failed treatment at lower level of care, and presence of co-morbid disorders impacting treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Findings:  Three physician reviewers found in patients with oligometastatic uterine cancer, there is risk of failure of local cancer control as well as metastases to multiple distant anatomic sites, not simply abdomen and pelvis. The physiologic tagging offered by PET is of high value in these patients. Physiologic tagging serves as a differentiating tool between post treatment fibrosis and persistent local tumor. Patients with oligometastatic cancer may have tumors at different and unexpected distant sites, such as the chest, scalp and axillary nodes.  It is important to identify these potential distant sites. Therefore, the requested PET scan is likely to be more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 1, 2 and 3 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: Urgent Care
Decision: Overturned

A 22-year-old female enrollee has requested urgent care services for the treatment of her spotting and vaginal discomfort. Findings:  The physician reviewer found that the issue to be decided is whether a reasonable and prudent layperson, taking into consideration the totality of the circumstances and the patients presenting history, would have believed she was experiencing an urgent medical condition on the date of service in question. Urgently needed services are those services necessary to prevent serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Plan's service area.  In this patients case, she presented on the date of service in question with complaints of cramps, spotting and discomfort. These complaints, in a young sexually active woman, can reasonably be considered urgently needed services. The patients symptoms would be sufficient to cause a prudent layperson to seek services while out of the Plans service area.  Based on the acute nature of the symptoms the patient was experiencing, the patient reasonably believed she was experiencing an urgent medical condition on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested for growth hormone (Nutropin) therapy for treatment of the enrollees hormone deficiency.  Findings:  The physician reviewer found that in the case of constitutional growth delay, catch-up growth occurs (albeit delayed) at the onset of puberty, and GH therapy is not indicated. Therefore, the distinction between GH deficiency and constitutional growth delay is important in establishing medical necessity for this patients treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes with peripheral neuropathy. The patient reported that she had received pregabalin. She requested brand name Lyrica. The patients medication records show that she received brand name Lyrica from at least February 2019 through June 2019. The patient noted that pregabalin caused blurred vision, dizziness and insomnia. Per the patient, pregabalin did not provide pain relief. The patient has requested authorization and coverage for brand name Lyrica. 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 brand name Lyrica is medically necessary for treatment of the patients medical condition. In this case, the patient received brand name Lyrica and subsequently received the generic pregabalin. The patient reported experiencing side effects and not tolerating this preparation. Although the bioactive fraction of the medication is bioequivalent, she might be experiencing side effects from the inert components, which might be different from the brand name Lyrica. The medical evidence supports the requested medication in this clinical setting. Therefore, brand name Lyrica 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 endocrinology, diabetes, and metabolism 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 is a 14-year-old male with a history of Arnold-Chiari malformation. He underwent neurosurgical intervention in November 2004.  The patient has had persistent headaches since the surgery. He was evaluated by an optometrist and diagnosed with accommodative dysfunction and binocular dysfunction. A request has been made for authorization and coverage for vision therapy with an optometrist. The Health Plan has denied this request.The patients optometrist indicates the patients diagnoses of accommodative dysfunction and binocular dysfunction are indications for vision therapy. No clinical notes have been provided demonstrating the patient has undergone a complete eye exam. There are no references to the patients visual acuity, refractive error, motility or neuro-ophthalmologic exam in the submitted materials.The above notwithstanding, the medical literature does not support the effectiveness of vision therapy. This therapy has not been proven to be effective for treatment of visual dysfunction. Thus, there is no evidence vision therapy is likely to have any clinical value in this case. Therefore, I have determined the requested therapy 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 patient has requested authorization and coverage for Epclusa 400 mg-100 mg tablets. According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive genotype 2 patients, based on clinical trials which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Given this patients diagnosis of chronic hepatitis C infection, genotype 2 without evidence of cirrhosis, the requested treatment with Epclusa is appropriate. For these reasons, the requested Epclusa 400 mg-100 mg tablets are 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 subspecialty 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

The father of a 5-year-old male enrollee requested authorization and coverage of admission to a partial hospitalization program for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary depending upon the results of an updated evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zulresso IV infusion treatment.The submitted records do not support that the requested medication is medically necessary. In treating postpartum depression, current literature recommends that add-on pharmacotherapy such as a second-generation antipsychotic, lithium, or triiodothyronine be added. For patients who are refractory to these sequential medication trials, ECT is recommended. In this case, while the patient has a diagnosis of postpartum depression, she has not had a trial of add-on pharmacotherapy such as a second-generation antipsychotic, lithium, or triiodothyronine. She has also declined electroconvulsive therapy (ECT). In addition, Zulresso (brexanolone) has only been studied for use in patients who are within 6 months of delivery, while the patient is now 12 months postpartum and would not be eligible for treatment with this medication. Under these circumstances, the requested Zulresso IV infusion treatment is not medically necessary to treat the patients medical condition, postpartum depression.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested Botox injections for medical treatment of her migraines.  Findings:  Three physician reviewers found that while Botox should not be considered a first-line therapy for migraine headaches, there is good literature for its use in well selected patients. In this particular case, the patient has failed a standard preventative and two abortive medications. In addition, she has had a noted benefit on Botox with reduced headache frequency. For these reasons, the continued use of this medication is warranted. Thus, the requested Botox is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the UroLift procedure for treatment of his benign prostatic hyperplasia. Three physician reviewers found that although UroLift received U.S. Food and Drug Administration (FDA) approval, long-term studies and comparative studies with transurethral resection of prostate (TURP) have not been completed or reported. In addition, the current American Urological Association (AUA) guidelines do not recommend UroLift as a treatment option in this clinical setting. Moreover, it is unlikely that the UroLift procedure will provide sufficient relief in this patient with such severe obstruction. For these reasons, the requested UroLift procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard modality.  Final Result:  Three reviewers determined that the requested services are 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: All three reviewers are board certified in urology 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

The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment services from a specific date and forward.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue in this patients case.  Clinical practice guidelines support residential level of care for patients with sub-acute psychiatric symptomatologies who are likely to fail in a less restrictive setting.  The purpose of this intervention is to consolidate treatment gains.  In this patients case, she continues to struggle with impulsivity, conflict negation, and affective dysregulation.  Per the submitted records, she does not yet have a stable psychotropic medication regimen.  Based upon the clinical documentation and current practice guidelines, residential treatment level of care was and is medically indicated.  All told, mental health residential treatment services provided from the date in question and forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested approval for past and future speech therapy twice per week for 60 minute sessions for treatment of his expressive and receptive language delay.   Findings:  The physician reviewer found that review of the submitted documentation reveals that the patient has an identified delay in expressive speech of 25-30% with a significant articulation disorder and delays in social skills. Speech therapy is medically indicated with any delay greater than 25% (Feldman and Messick). An extensive review of the literature including a meta-analysis by Law and colleagues noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Gallagher and colleagues evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention (Gallagher).