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

A 52-year-old male enrollee has requested a motorized wheelchair for the treatment of his degenerative joint disease. Findings:  The physician reviewer found that the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Specifically, the following have not been documented in the medical records provided for review: 1) limited mobility that impairs the patients ability to perform one or more mobility related activities of daily living; 2) inability of a cane or walker to resolve the functional mobility deficit; 3) inability of the patient to self-propel a manual wheelchair; 4) ability of the patient to safely operate a power wheelchair; and 5) capacity of the patients home environment to accommodate a power wheelchair.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a sixteen year-old female with a history of drug and alcohol use is requesting reimbursement for residential treatment services.  Reviewers Findings:The reviewing physician found that a transition from inpatient psychiatric treatment to residential treatment was recommended by the patients outpatient therapist, however the specific indications for this level of care are not clear.  The physician also found that the services at issue were not medically necessary for treatment of the patients medical condition.  The reviewing physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy solution auto-injector 24 mg/0.75 mL. Gadde and colleagues note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. Friedrichsen and colleagues report that in adults with obesity, once-weekly subcutaneous semaglutide (brand name Wegovy) 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. Given this patients history of obesity complicated by hypertension and hypertriglyceridemia, the requested medication is medically indicated. Therefore, Wegovy solution auto-injector 24 mg/0.75 mL 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: Experimental/Investigational
Decision: Overturned

An 18-year-old female has requested coverage for Humira for treatment of her orbital myositis.  Findings:  Three physician reviewers found that the patient has a complex medical history. The issue at hand is the patients history of orbital myositis and the treatment options available to her. She has had serious side effects from systemic corticosteroid use, including osteopenia. She was treated with methotrexate and CellCept, neither of which was effective. She also has received external beam irradiation and now her providers are requesting Humira as a treatment option. Orbital myositis, or orbital inflammatory syndrome, is an orbital inflammatory process which can be difficult to treat. The standard first-line treatment has been systemic corticosteroids. A biopsy is usually warranted if a typical response to corticosteroids is not evident, or if more aggressive chemotherapy is pursued. This patient is presently in a difficult situation as further corticosteroids will cause more serious systemic side effects, and all other chemotherapeutic agents have been ineffective or poorly tolerated. Any benefit from external beam irradiation would at this point be manifested, however the patients inflammation persists, therefore the use of Humira is clinically reasonable. There is literature describing the safety and effectiveness of Humira in idiopathic orbital inflammation, and a trial to assess its efficacy is warranted in this situation where no other options are presently available. Humira has been utilized for other chronic idiopathic inflammatory conditions such as rheumatoid arthritis and Crohns disease, so the peer reviewed medical literature supports its use in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested authorization and coverage for orthodontic treatment. Based on the available documentation, this patients clinical presentation does not support an indication for orthodontic treatment. To assess the need for orthodontic treatment there are many tools to quantify the degree of handicap caused by the malocclusion. One commonly used tool is the Handicapping Labiolingual Deviation (HLD), as used here. A score of over 25 on the HLD is a severe malocclusion requiring orthodontic intervention. In this case, the patients HLD score is below the cut off for orthodontic services. Additional issues such as bite impinging on the palatal tissue, spacing or occlusion, which prevents normal chewing, are further indications for orthodontic treatment. However, none of these conditions was documented in this patients chart. Given the patients Class I malocclusion, HLD index score, and no significant medical condition to lead to a medical exception, orthodontic services are not supported as medically necessary. Therefore, the requested orthodontic treatment 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 dentistry 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: The parent of an enrollee has requested authorization and coverage for Lyrica for treatment of the enrollees chronic daily headache, generalized anxiety disorder, and major depression. Findings: The physician reviewer found that based on the medical records, the patient has a history of debilitating migraine headaches which has significantly impacted his ability to go to school. This in turn is likely to contribute to loss of self-esteem, increased anxiety and other emotional stress, all of which could contribute to his depression. Lyrica has been demonstrated to have significant efficacy compared to the historic benchmark agent, propranolol which parenthetically is contraindicated in this patient because of its potential to cause depression in reducing headache frequency. Therefore, using Lyrica makes good therapeutic sense for this patients pharmacotherapeutic regimen, particularly with respect to his headaches. Accordingly, the requested Lyrica is supported as medically necessary for treatment of this patients medical condition.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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested an Amnisure test for the evaluation of her medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  There is no history provided to suggest that this patient had ruptured her membranes, and the record does not indicate that a physical or pelvic examination was performed.  The diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation.  In equivocal cases, additional tests may aid in the diagnosis.  Per the submitted documentation, there is nothing in the record to suggest that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that these standard evaluations were performed.  The routine use of Amnisure to diagnose ruptured membranes is not recommended.  Therefore, an Amnisure test was not likely to be superior over other methods of evaluation.  Final Result: Three 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: All three reviewers are board certified in obstetrics and gynecology 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 43-year-old female enrollee has requested panniculectomy/abdominoplasty and bilateral breast lift for treatment of her redundant skin condition.  Findings:  The physician reviewer found that the records do not establish medical necessity for the proposed panniculectomy/ abdominoplasty or breast lift. The patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that (1) are plainly related to the excess skin (2) are health threatening or cause significant functional disability and (3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. The proposed procedures do not meet this standard as there is no documentation over time of skin infections in the abdominal folds or under the breasts (e.g., series of office notes, dermatology consultations, or prescription records) and no photographs documenting cellulitis, ulcerations or rashes were submitted. Additionally, the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss has not been satisfied as the records do not document panniculitis or the failure of medically supervised conservative therapy to control intertrigo. Breast lift and panniculectomy/abdominoplasty may be desirable for aesthetic reasons, but they are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the head, jaw, neck, ears, and throat. Per the National Comprehensive Cancer Network (NCCN) guidelines, for patients with Hodgkin lymphoma, in the long-term follow-up, there is no indication for MRI. The records document that this patient has been evaluated with a computed tomography (CT) of the sinuses, neck, and thorax. The CT of the sinuses noted mild mucosal thickening in the bilateral maxillary, ethmoid, and frontal sinuses, mild deviation of nasal septum, and possible 7 mm left nasal polyp. The CT of the thorax showed mild emphysematous changes, aortic and arterial atherosclerosis, stable bi-apical scarring and coarse calcifications associated with focal pleural thickening on the left. These findings and the providers impressions do not support an indication for further imaging with MRI. Moreover, the clinical notes and physical assessment findings do not suggest that MRI findings would be beneficial for this patients care. Given these findings, the requested MRI of the head, jaw, neck, ears, and throat is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 intensive outpatient treatment (IOP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the data reviewed are incompatible with both the American Psychiatric Association and American Society of Addiction Medicine (ASAM) guidelines for this level of care. Per the peer-to-peer review documentation submitted by the Health Plan, the patient was motivated for treatment and compliant with the program. He was apparently working on issues of self esteem. There is no evidence of serious medical concerns and no evidence of potential serious risk to self or others related to his substance abuse. His parents were supportive of recovery. Thus, there was no indication for continued IOP services. APA guidelines indicate that patients should be treated in the least intensive setting which will be safe and effective. The information submitted fails to establish that an IOP setting was the least intensive viable setting for treatment in this case. Additionally, there was no indication of an intensification of symptoms, that the patient lacked sober social supports, or that he was resistant to treatment. As such, the submitted documentation does not establish that dimensions 4-6 of the ASAM placement criteria were met during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested coverage for two hours per week of speech therapy and two hours per week of occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that with regard to the requested speech therapy, while the patient is profoundly delayed in speech, his speech therapist did report some gains (though minimal) after one year of therapy.  Myers and Johnson state, Most children with ASDs can develop useful speech  traditional, low-intensity pull-out service delivery models are ineffective  speech-language pathologists are likely most effective when they work  to promote functional communication throughout the day. Turner, et al. reported on the success of an integrated speech and behavioral program in a controlled study, with the speech therapy group having far better communication skills at the age of 9 than the non-intervention group (e.g., school program, limited services, etc.). Goldstein discussed the various speech treatment modalities and their application to autistic children. Based on the medical literature discussed above, as well as the fact that this patient showed some response to prior therapy, there is adequate evidence to support the medical necessity of speech therapy in this setting. The patient should receive individual speech therapy for one hour two times per week. Concerning the requested occupational therapy, the paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population. Schaaf, et al. noted success with sensory integration occupational therapy in an autistic patient population. While this patient is severely delayed, there is evidence that he has the capacity to benefit from rehabilitative therapies (given his documented response to speech therapy). As such, the patient is an appropriate candidate for occupational therapy, which is part of the standard treatment protocol for patients with autism. The patient should receive occupational therapy for one hour two times per week.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Dupixent. The enrollee has a history of severe, refractory atopic dermatitis and persistent, uncontrolled asthma. She had been treated with steroid creams and immunotherapy. A progress note reported the enrollees skin is clear of rashes, except for eczema to the face, waist and groin area. The note reported the enrollees scalp and nails were normal. Medical records do not demonstrate the enrollee has atopic dermatitis on at least 10 percent of the body or more. The medical records do not show the enrollee had attempted treatment with topical tacrolimus or topical pimecrolimus and then one of the following: phototherapy, methotrexate, azathioprine, intermittent/pulse therapy with oral steroids, mycophenolate mofetil, or cyclosporine. The physical examination of the lungs and skin were reported as normal. There is no mention of prior use of Dupixent in the notes provided. The progress notes do not mention the prior use of systemic immunomodulatory drugs or calcineurin inhibitors for atopic dermatitis. A pharmacy services note shows that a mild steroid cream and Eucrisa had been used in the past. There is inadequate evidence to support moderate to severe atopic dermatitis, based on the medication trials and physical examination findings documented in the progress notes provided.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in allergy and immunology 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: An enrollee has requested authorization and coverage for Technivie 12.5-75-50 mg medication, for quantity of 14 tablets for a 14-day supply. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The AASLD/IDSA guidelines recommend that treatment naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks. This guideline recommendations is based on the PEARL-1 trial, which demonstrated a 100% cure rate in this population. However, this patients records do not include a documented plan to use ribavirin. Thus, the requested treatment with Technivie for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 Otezla. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis with joint involvement that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla is medically necessary for treatment of the patients medical condition.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.