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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Reglan for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Gastroparesis is a common cause of nausea in patients with diabetes.  Reglan is effective for the treatment of diabetic gastroparesis.  It is associated with tardive dyskinesia based on certain trials, although prospective data is lacking.  Camilleri and colleagues noted metoclopramide (Reglan) is the first line of prokinetic therapy and should be administered at the lowest effective dose in a liquid formation to facilitate absorption. The risk of tardive dyskinesia has been estimated to be less than 1%.  This patient has done well with Reglan, and still needs Zofran occasionally for nausea.  Based on clinical literature, the use of Reglan is supported in this case, with well-documented discussion of side effects with the patient.  All told, Reglan is medically indicated 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: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested hyperbaric oxygen therapy treatments for treatment of her hearing loss. Findings:  Two physician reviewers found that the submitted evidence suggests the patient's recent history of upper respiratory tract infection may have had an influence on the genesis of her disorder which was appropriately managed with the anti-inflammatory steroid therapy. Although hyperbaric oxygen therapy has proven beneficial for a number of other disorders, controlled trials of its use in the treatment of idiopathic sudden sensorineural hearing loss remain limited at this time. In this patients case, it is uncertain whether or not the treatment using the oral steroid therapy alone which was started well before the hyperbaric oxygen therapy began to have some improvement or whether the additional use of the hyperbaric oxygen therapy assisted in the improvement of the patients medical condition. In summary, there is not enough clinical evidence at this time to support the use of HBOT in the treatment of idiopathic sudden sensorineural hearing loss. Based on the clinical controlled trials, most of the patients who underwent HBOT also received oral steroid therapy. The controlled trials performed do not show any difference in benefit in the patients who received HBOT alone versus those who received steroid therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dopamine transporter single photon emission computed tomography (DaT SPECT) scan for evaluation of his tremor in bilateral hands and legs. Findings:  Three physician reviewers found that researchers concluded that DaT scan imaging has an impact on clinical decision making. Further, the authors noted that DaT scan has the potential to provide support in diagnosis, especially for those patients who have an unclear presentation of Parkinsonian syndrome (PS). Similarly, other researchers reported that an accurate diagnosis is important for timely and adequate treatment in patients with clinically uncertain parkinsonian syndrome (CUPS)DaTscan imaging significantly affected the clinical management and diagnosis of patients with CUPS. Thus, the literature does support the use of DaT SPECT imaging to assist in the diagnosis in patients with suspected parkinsonian syndromes and help guide treatment decisions. Final Result: The reviewers determined that the diagnostic procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply). Findings:  The physician reviewer found that he patient has a history of anxiety and the records suggest that the patient may benefit from psychiatric evaluation and treatment. He has been off Xanax for over a year, and is not currently managed on any benzodiazepines, given their contraindication to opioid treatment. The patients current medication regimen includes prescriptions for pain management medications such as Cymbalta, Wellbutrin, hydroxyzine, and gabapentin, which may also be utilized for the treatment of anxiety. In this clinical setting, while there is room for adjustment of the patients psychotropic medication regimen to target anxiety symptoms, given that benzodiazepines are contraindicated alongside high dose opioid therapy, restarting the requested medication is not medically indicated. In this patients case, Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply) is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Xanax 1 mg two to three tablets daily as needed (dispense 70 tablets/30 day supply) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings:  The physician reviewer found that Facial laser hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. She has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iron sucrose injections for treatment of the enrollees low ferritin levels. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The medical literature indicates that approximately 70% of patients experience gastrointestinal side effects to oral iron. Intravenous (IV) iron is considered a standard of care for many patients, especially those that cannot tolerate oral iron. There are a number of settings in which the use of IV iron may be preferable to oral iron: patients who cannot (or prefer not to) tolerate the gastrointestinal (GI) side effects of oral iron, patients who prefer to replete iron stores in one or two visits rather than over the course of several months, ongoing blood loss that exceeds the capacity of oral iron to meet needs (e.g., heavy uterine bleeding, or mucosal telangiectasia), anatomic or physiologic condition that interferes with oral iron absorption, or coexisting inflammatory state that interferes with iron homeostasis. This patients records indicate that she meets several of the criteria noted above. She has not been able to tolerate oral iron due to GI side effects and she has heavy uterine bleeding. For these reasons, the use of intravenous iron is reasonable and medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to the conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an insulin pump and continuous glucose monitor (CGM). Current studies have shown that tight glucose control reduces the risk, delays the onset, and slows the progression of complications. According to the American Diabetes Association (ADA), most adults with type 1 diabetes should be treated with intensive insulin therapy with either multiple daily injections or an insulin pump. Pump therapy can be successfully started at the time of diagnosis and has been shown to be superior in lowering hemoglobin A1C over multiple doses of insulin. Regarding continuous glucose monitor (CGM) devices, the ADA recommends sensor-augmented pump therapy may be considered for adults to improve glycemic control without an increase in hypoglycemia or severe hypoglycemia. The ADA reports that benefits correlate with adherence to ongoing use of the device. Further, an International Consensus on Use of Continuous Glucose Monitoring states that CGM should be considered in conjunction with hemoglobin A1C for glycemic status assessment and therapy adjustment in all patients with type 1 diabetes and patients with type 2 diabetes treated with intensive insulin therapy who are not achieving glucose targets, especially if the patient is experiencing problematic hypoglycemia (Danne, et al). Moreover, the Dexcom CGM recommended by this patients provider is the most effective and efficient management of this patients diabetes type 1. The Dexcom CGM is a real-time monitor that provides immediate feedback, alarms and predictive alarms when glucose levels are trending high or low, allowing the patient to manage her diabetes and prevent dangerous levels of hypoglycemia and hyperglycemia. As a result of improved control, the patient will be at lesser risk for diabetes related complications. Accordingly, the requested insulin pump and CGM are medically necessary for treatment of this patients type 1 diabetes. Final Result: The reviewer determined that the requested equipment 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 diabetes, endocrinology 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested reimbursement for fecal calprotectin test. The enrollee has a history of poor linear growth velocity despite adequate weight gain.  Documentation from an office visit indicates the enrollees growth had been tracking around the 50th percentile until age two, decelerated to the 25th percentile at age three, and dropped to the 10th percentile by age five. Patients body mass index (BMI) had been tracking along the 50th percentile in this time frame.  The enrollee has had no abdominal pain, fatigue, headaches, changes in bowel habits, loose stools or constipation. Bone age results were normal. Due to the enrollees family history of Crohns disease and unexplained growth failure, the provider ordered a fecal calprotectin lab test to evaluate for possible inflammatory bowel disease.  These results were normal. Literature shows fecal calprotectin (FC) can accurately test for bowel inflammation, but it is not site-specific. The test can potentially be used to differentiate between irritable bowel syndrome (IBS) and other inflammatory diseases, but to rule out Crohns disease definitively, imaging diagnostics, such as computerized tomography (CT) scanning or magnetic resonance enterography (MRE) and endoscopy are used. Research is ongoing to determine the feasibility and reliability of using FC to diagnosis IBS in children. Studies showed 12-36% of patients with IBS also have elevated FC. However, the testing is more appropriate for those with a higher chance of having the disease. Studies do not demonstrate FC testing affects overall management, treatment or outcome for children with poor linear growth.  In this case, the enrollee has poor linear growth with no intestinal symptoms, anemia or bloody stools. Additionally, there is no robust data supporting use of calprotectin among asymptomatic children with short stature or that this assay improves outcomes for an asymptomatic pediatric population.Final Result: Three of the three reviewers determined that the requested service was not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in pediatric gastroenterology 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 30-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the left knee for an evaluation of his left knee pain. Findings:  The physician reviewer found that evidence of instability, effusion or an abnormal x-ray or physical exam is necessary in order for an MRI to be indicated. This patient has no indication for MRI of the knee by any accepted guidelines. A trial of conservative treatment and/or referral to a specialist is the next appropriate step in this setting. An MRI is not medically necessary for evaluation of the patients knee pain without first exhausting conservative treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 28-year-old female enrollee has requested Botox injections (on a 10-week frequency) for treatment of her migraine headaches.  Findings:  Two physician reviewers found that although Botox is not a first-line therapy for migraine or chronic headaches, there is adequate literature citing its use for these conditions.  For this particular patient, she has failed multiple first-line preventative therapies for migraine headache. Furthermore, she has already experienced a documented beneficial effect from treatment with Botox. Based on the literature, the patients failed response to conventional medical therapy, and the documented relief of her symptoms secondary to treatment with Botox, its continued use is medically appropriate. The literature suggest re-treatment approximately every 3 months, thus, that frequency is likely adequate as this patient reported relief lasting about 10 weeks.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested Xyrem 500mg   for treatment of her intractable insomnia. Findings:  The physician reviewer found that the patient has a long history of severe insomnia resistant to numerous hypnotics and sleep-inducing agents. The untreated insomnia is worsening her chronic pain associated with fibromyalgia, depression and anxiety. This patient had a high amount of alpha waves intruding into delta sleep.  Xyrem has been shown to improve delta sleep.  Thus, Xyrem is effective in this clinical scenario. There is sufficient evidence in the medical literature supporting the use of Xyrem to treat this patients insomnia and improve the quality of her sleep.  This patient does not have apparent contraindications to this medication.  The current medical evidence supports the requested medication for the treatment of this patient.  All told, Xyrem 500mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Norco four times per day and Soma three times per day for treatment of her chronic pancreatitis.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose, short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the patient should be weaned off of Norco and Soma. Short acting opiates are more likely to cause adverse outcomes and therefore the patients requested authorization and coverage for Norco and Soma is not indicated. Consistent with these findings, the Norco and Soma as requested by the patient is not supported as medically necessary for treatment of her medical condition.