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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dutasteride (Avodart) for treatment of his skin condition. The physician reviewer found that androgenetic alopecia (AGA) develops with a distinctive patterned hair line recession. Research on patients with androgen insensitivity syndromes, or 5 alpha-reductase deficiency, suggest that AGA is induced via activation of androgen receptors in hair follicles by dihydrotestosterone (DHT). The primary precursor of DHT in men is testosterone. The density of androgen receptors in hair follicles varies with location. Drug therapies specifically approved for treating AGA are limited to minoxidil and finasteride. Avodart is approximately three times more potent than finasteride. Clinical trials for AGA have demonstrated a dose-dependent increase in hair growth with Avodart. The available medical records indicate that this patient has AGA with the hair loss improved on Avodart. He also had folliculitis treated with a topical corticosteroid and has been treated with anti-fungal therapy for possible tinea capitis. Since the efficacy of Avodart for the treatment of AGA is superior to finasteride, and Avodart has been already successfully used by this patient, the requested Avodart is supported as medically necessary. Final Result: The reviewer determined that the medication dosage at issue was and 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acupuncture. The records provided for review document that this patient has a history of low back pain. The patient has been treated with chiropractic therapy and acupuncture. The patients provider has recommended continued treatment with acupuncture. As noted by Liu and colleagues, Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP [low back pain]. Regarding the use of acupuncture for chronic pain, MacPherson and colleagues reported that, the effects of acupuncture compared to no acupuncture for chronic pain do not appear to decrease importantly over 12 months. The available records state that prior acupuncture care was beneficial for this patient. However, there is a lack of documentation of pre-acupuncture and post-acupuncture baselines of activities of daily living, range of motion, medication intake, and level of function to support an indication for additional acupuncture. In addition, the total number of sessions completed, and any measurable, significant, objective functional improvement obtained with previous acupuncture was not reported to support additional acupuncture services. Moreover, a current physical examination was not documented with clinical findings specifying the deficits to be addressed with additional acupuncture. For these reasons, the requested acupuncture 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.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee requested skin injections and a referral to a dermatologist for medical treatment of the enrollees psoriasis.   Findings:  The physician reviewer found that this patients records do not include a biopsy to support a clinical diagnosis of psoriasis. This patient indicates that her condition worsened and spread to other parts of the body since discontinuation of injections. Considering the known side effects from chronic corticosteroid use, the requested intralesional Kenalog treatment is not medically necessary for treatment of this patients medical condition. All told, the patient needs to be referred to a dermatologist for diagnosis and treatment. Therefore, the requested referral to a dermatologist is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Glassia for treatment of her medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested medication.  The selection of appropriate patients in this scenario is critical, including a high-risk phenotype or a specific plasma alpha-1 antitrypsin level in a non-smoker or ex-smoker.  Since this patient is neither, she does not meet the criteria.  In this clinical setting, standard bronchodilator therapy and oxygen if indicated are appropriate.  Therefore, Glassia is not likely to be of greater benefit than other treatment options. Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy.  Findings:  Three physician reviewers found that there is a lack of medical literature demonstrating that treatment with intraoperative radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer.  Furthermore, current guidelines state that two clinical trials revealed that the risk of recurrence was higher with intraoperative radiation therapy than with standard treatment with whole breast radiation.  In sum, the requested intraoperative radiation therapy is not likely to be more effective than other treatment alternatives in this patients case. Final Result: 2 of 3 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 physician reviewers are board certified in radiation oncology 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 42-year-old male enrollee has requested Cialis 20mg, 30 tablets per month for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that this patient has erectile dysfunction. Erectile dysfunction is felt to be multifactorial in origin, and the medical records do not conclude a reason for his symptoms of erectile dysfunction. The references demonstrate that Cialis is very effective in improving erectile dysfunction. However, the medication has not been shown to be more effective in treating the medical condition when taken on a daily dosing schedule. The medical literature does not support a medical need to take the medication on a daily basis. Coverage for 6 tablets of Cialis 20mg per month as authorized by the Health Plan is within the standard of care and medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested continued rehabilitation and nursing services for treatment of her left-sided weakness from a stroke.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The patient had a thalamic stroke, which has limited rehabilitation outcomes (Vogt et al). She has received six weeks of rehabilitation without change in her functional status. The patient remains at moderate assist with transfers, minimal assist for bed mobility and maximal assist for toileting. The patient has performed inconsistently with transfers, which suggests that full recovery capacity has been reached as she fluctuates between minimal/moderate assist to moderate assist (Kaira). Although the patient may make additional progress, the progress must await any additional neurological recovery. Daily skilled therapy will have no impact on the patients neurological recovery. Based upon the documentation provided, the medical necessity of continued rehabilitation and skilled nursing services has not been established. As such, the services at issue are not considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-five year-old female with chronic constipation is requesting authorization and coverage of Amitiza.Reviewers Findings:The reviewing physician found that Amitiza has provided the patient with some relief form the chronic constipation and is the agent of choice in this clinical situation.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Medical literature reports that irritant contact dermatitis is often caused by cumulative exposure to weak irritants, accounting for 80% of all cases of contact dermatitis, and may co-exist with atopic dermatitis and allergic contact dermatitis, with pruritus classically reported by these patients. Researchers note that systemic contact dermatitis refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route. Per the authors, current treatment options include topical steroids and oral antihistamines for symptom relief and dietary avoidance to causative foods or metals. In this case, the patient presented with a pruritic rash. The patient was prescribed betamethasone and Zyrtec. Given that the patient had failed to respond to over-the-counter medication, the services rendered were urgent care services, defined as services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The patient presented again for evaluation for a vulvar mass that had been present for two months. Given that the patients symptoms were not sudden in onset and there was adequate opportunity for the patient to seek care on a non-urgent basis, the services provided were not urgent care services, defined as services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury.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 emergency 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: Upheld

A 20-year-old male enrollee has requested for an MRI of the brain and sinuses for evaluation of his facial and sinus pain. Findings:  The physician reviewer found that CT of the sinuses is accepted as useful in diagnosing sinusitis, in conjunction with relevant clinical and laboratory findings. No clinical differential diagnosis is recorded. A thorough exam should be performed of the head and neck area, as well as an appropriate neurologic exam.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for positron-emission tomography scan. The enrollee has non-secretory myeloma. The disease progressed and he underwent induction chemotherapy in preparation for an autologous transplant. He received the transplant and one of his chemotherapy agents, Revlimid, was resumed several months later. At a six-week follow-up office visit, he expressed concern regarding a trace amount of blood in his  stool and was advised to see a gastroenterologist if he had any increase in the bleeding and plan for an anoscopy, colonoscopy, or both. A computerized tomography (CT)/positron-emission tomography (PET) scan was ordered to check the status of the myeloma.  The CT scan report indicated no active lesions in the skeletal system while the PET scan showed the enrollees status had slightly improved, with no signs of progression identified. The medical literature indicates bone marrow aspiration biopsy and imaging studies with magnetic resonance imaging (MRI) and/or computed tomography (CT) and/or whole-body fluoro-deoxyglucose (FDG) positron-emission tomography (PET)/CT are recommended as clinically indicated for a patients course of treatment.  PET imaging reliably predicts active myeloma.  It can also assess the extent of active disease, detect extramedullary involvement, or evaluate treatment response.  The literature recommends considering using the same imaging modality used during the initial work-up for the follow-up assessments.  The record indicates the enrollee had previously had a PET scan prior to his autologous transplant. He has not undergone additional imaging since the transplant.  A PET scan is indicated to assess treatment response following the enrollee's autologous transplant, as well as to assess the continued use of Revlimid.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested authorization and coverage for acupuncture. The enrollee has a left heel spur and history of bunion surgery. She has a diagnosis of plantar fasciitis with throbbing pain when she is standing in one place and walking. It prevents her from doing her everyday activities. Findings:  The physician reviewer found that the enrollee wears orthotic shoes and applies heat with Epsom salt baths to alleviate pain. She has had cortisone shots, physical therapy, exercises, foot massage and medications. She was referred for acupuncture as her pain level was 10/10 and she was limping with a poor quality of life. The enrollee indicates the acupuncture has been successful to manage pain. However, there is a lack of peer-reviewed literature to support the safety and long-term efficacy of acupuncture for this enrollee's diagnosis. Results from a number of studies suggest acupuncture may help ease types of pain that are often chronic, such as low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the frequency of tension headaches and prevent migraine headaches. Two articles address the use of acupuncture for the relief of heel pain with high significant outcome. However, these are based on small samples and lack evidence supporting the use of the acupuncture for plantar fasciitis.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications:  The reviewer is board certified in acupuncture 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old male with a longstanding history of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder. The patient was previously treated with Adderall XR, which was followed by a combination of Adderall XR and Strattera, and then only Strattera. A request has been made for continuation of combination therapy with Adderall XR and Strattera. The Health Plan has denied authorization and coverage for the requested therapy on the basis that it is not medically necessary.The notion of combining psychotropics for off-label treatment of a variety of conditions has support in the psychiatric community. Given the relative newness of Strattera, there perhaps has not been enough time for case reports or formal studies on combination therapy to surface. In the case of this patient there is documented evidence from the patients psychiatrist of a clear improvement with a combination of Adderall XR and Strattera, with no indication of untoward side effects. In October 2003, the patients provider indicated the patient appeared to be doing well on a combination of Adderall and Strattera as he had a decrease in lability, was not fighting, was smiling spontaneously and had improved energy. This is in contrast to the earlier documentation, which noted the patient was not doing well academically and was lethargic when receiving only Adderall XR. In addition, it was noted that the patient was extremely oppositional and not doing his schoolwork when receiving Adderall and imipramine. The submitted records demonstrate the patient experienced only minimal response to single agent therapies. However, it appears he responded extremely well to the combination of Adderall XR and Strattera, with much better attention in school, proportionately better grades, and less acting out. Subsequent treatment with regular short-acting Adderall and Strattera was not as successful. Given the documented evidence that combination Adderall XR and Strattera was successful in overriding the patients oppositional behavior, continuation of such therapy is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested combination therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has a congenital expressive aphasia. Cognitive studies have indicated that she is likely of normal intelligence. She has made definitive gains, demonstrated by testing on the RITLS, during a 5-month period of 1 hour of weekly speech therapy.  Children with speech delay can be effectively treated with speech therapy, as confirmed in a meta-analysis of multiple medical journal articles (Law, et al.). Goorhuis-Brouwer, et al. specifically studied speech-delayed children with normal intellect, such as this patient, and found that such children are ideal candidates for successful speech therapy. Two-year olds who test below the 10th percentile for their age often require and benefit from speech therapy (Emmanues, et al. and Buschman, et al.). All told, speech therapy is medically indicated in this patient and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Foundation One assay is a molecular assay that explores the mutations of an individuals cancer cells. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. A randomized trial by researchers failed to demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. Therefore, gene panel testing was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested carotid angioplasty with stent placement for treatment of his carotid artery stenosis.  Findings:  Two physician reviewers found that given the clear indication for carotid revascularization and the patients increased risk for conventional endarterectomy surgery due to multiple comorbidities, remote CABG, and moderate provokable ischemia on stress testing, it is reasonable to consider alternative revascularization procedures. This procedure is less invasive and is strongly recommended by the treating physician. It is reasonable and appropriate under these circumstances of higher operative risk to proceed with angioplasty and carotid stenting.