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

An enrollee has requested authorization and coverage for Xeljanz 5 mg tablets.The medication Xeljanz (tofacitinib) is off label for the treatment of alopecia areata. There are many peer reviewed studies regarding the use of this medication in the treatment of alopecia areata. Researchers conducted a study to compare the efficacy and tolerability of oral tofacitinib and conventional modalities for treating refractory alopecia totalis/universalis. They concluded that oral tofacitinib was more effective than diphenylcyclopropenone immunotherapy and more tolerable than conventional oral treatment after six months of treatment. In this case, the patient has experienced a rapid worsening of her disease process in the last three months. The patient has first line treatment with intralesional steroids, which she responded to initially, albeit slowly. The patients alopecia areata is affecting her quality of life and is impacting her eyes, as she has more irritation without her eyelashes. At this time, the patient is refractory to conventional treatment with worsening disease severity.  Under these circumstance, the requested medication, Xeljanz 5 mg tablets, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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

A 43-year-old male enrollee has requested a xiphoidectomy for treatment of her xiphodynia.  Findings:  The physician reviewer found that this patient is an example of an infrequently diagnosed condition of xiphodynia. This can occur after repeated trauma, direct injury, or without explanation. In the medical literature, xiphoid deformities have been associated with pain. In the Tack Hammer Deformity, the tip of the xiphoid is acutely angled and this pressure causes pain. Referred pain is also possible given the involvement of the lower intercostal nerves, anterior branches of the iliohypogastric and ilioinguinal nerves, and the phrenic nerve (Simpson and Hawken). The standard treatment for this condition includes anti-inflammatory medications, ice, and injections. In the rare patient who fails medical treatment, xiphoidectomy is recommended (Lipkin, et al; Hanlon and Miller). All told, this patient meets the criteria for the requested surgical procedure. Therefore, the requested xiphoidectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested authorization and coverage for endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance for treatment of back and leg pain.   Findings:  Three physician reviewers found that the patient is a 60-year-old female with back and leg pain. Her provider noted a long history of back problems, with a prior fusion for scoliosis from T3-T10, and a later extension T10-L4.  The medical records noted that the patients back pain had increased over the years, significantly for six months, with left lower extremity pain, as well as neurogenic claudication. Conservative measures were unsuccessful.  On examination, motion was limited in the back. Straight leg raising was negative bilaterally. Strength was intact.  X-rays were described as showing grade 2 spondylolisthesis at L4-5, with disc degeneration, severe at L4-5, and moderate at L5-S1. An MRI was described as showing severe spinal stenosis at L4-5. An MRI of the lumbar spine was then performed.  At L4-5, there was narrowing.  At L5-S1, there was right paracentral and foraminal protrusion, without canal or foraminal stenosis. In an addendum, this was described as also involving the left foramen.  Approximately two months later, the provider noted that the patient had been seen for over five years for thoracic and lumbar pain, with recent increased lumbar spine problems, not controllable with medications, epidural or nerve block injections. The medical records noted that prior treatments included physical therapy, medications, and a TENS unit.  On examination, there was limited motion and tenderness in the lumbar spine, decreased sensation, 1+ reflex at the knees and ankles, and good strength. The patients diagnoses included bilateral foraminal stenosis L4-L5, with disc protrusion and spondylolisthesis, and at L5-S1, disc bulge.  The patient has requested authorization and coverage for endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  At this time, the superior efficacy of the requested services has not been established. In the attempt to avoid the problems associated with open surgical procedures, there has been interest in more minimal approaches, such as endoscopic procedures and microdiscectomy, and different techniques, such as the axial lumbar interbody fusion. Encouraging early results have been reported for endoscopic procedures, but the need for randomized, controlled studies has also been noted. A similar situation exists for the axial approach, with some encouraging reports in the literature, but also reports of complications, pointing to the need for further study.  In this patients case, the requested endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tranylcypromine. Findings: The records document that this patient presents with a history of major depressive disorder non-responsive to multiple therapies including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), transcranial magnetic stimulation (TMS), and ketamine. In this case, the patients depression responded to the maximum U.S. Food and Drug Administration (FDA) recommended dosage of tranylcypromine 30 mg twice daily. The patients provider recommended titrating the dose to 40 mg twice daily to achieve remission. Per the FDA approval, tranylcypromine is indicated for the treatment of major depressive disorder in adult patients who have not responded adequately to other antidepressants. Studies have reported that patients who have not responded to multiple medication classes are likely to benefit from treatment with tranylcypromine. One study noted that tranylcypromine is being increasingly considered as a viable treatment option for patients experiencing severe courses of depression, such as treatment resistant depression and atypical depression. Another study reported that eight of 27 patients remitted with initial dosing of tranylcypromine up to 60 mg per day and six of 18 patients showed signs of remission with dosing up to 120 mg per day. In addition, a recent study of 28 patients with treatment resistant depression found that 21% of patients treated entered remission with an average higher tranylcypromine dose of 105 mg per day. Given these findings, the requested tranylcypromine is appropriate for management of this patients depressive symptoms. Moreover, the requested tranylcypromine is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the requested tranylcypromine is medically necessary for 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 psychiatry with subspecialty certification in preventive 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that the superiority of Botox over standard migraine preventive medications has not been sufficiently established.  It does not appear that this patient has exhausted standard preventive medications. In the absence of evidence demonstrating that the patient has attempted adequate trials of standard agents without success, the use of Botox is not supported.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested wearable cardioverter defibrillator for treatment of his congestive heart failure.  Findings:  Two physician reviewers found that patients that present with new congestive heart failure (CHF) and profound impairment of cardiac function are at elevated risk of sudden cardiac death. Epstein and colleagues reported on the role of the implantable cardioverter defibrillator (ICD) use in primary prevention of sudden cardiac death in this patient population. The authors also noted that placement of the ICD at the time of diagnosis is non optimal with regard to the benefits. However, there is a paucity of randomized controlled studies demonstrating that the LifeVest wearable cardioverter defibrillator is equivalent or superior to standard alternatives during this waiting period. In the absence of a proven benefit, the LifeVest was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing performed for evaluation of the enrollees behavior condition. Findings: The physician reviewer found that medication and psychotherapy have strong evidence based support for their use in this clinical setting. Conversely, it is unclear if genetic testing has been used in an evidence based manner. As such, the evidence based literature does not support the use of pharmacogenomic testing in cases like this one. Kirchheiner and colleagues note the following, there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. Moreover, the documentation provided does not indicate specific medication doses used, length of medication trials or combinations of medications tried and failed.  Additionally, the records do not indicate whether or not this patient has had cognitive behavioral therapy (CBT) for her generalized anxiety disorder diagnosis. CBT has proven efficacy and is considered first line therapy for treatment of this patients medical condition.  Accordingly, the genetic testing performed was not likely to have been more effective than the standard methods of evaluating this patients medical condition.Final Result: All three physician 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 physician reviewers are board certified in psychiatry and are actively practicing. The reviewer 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

A 56-year-old female enrollee has requested for a temporomandibular joint (TMJ) steroid injection for treatment of her TMJ. Findings:  The physician reviewer found that the use of diagnostic and therapeutic TMJ injections is a very common modality employed in the non-operative treatment and diagnostic workup of TMJ disease. It is an easily accomplished, low risk procedure, which can help to subvert the need for surgical intervention in certain cases. The use of intra-articular corticosteroid injections is a common modality that is employed in all kinds of arthritic conditions involving inflammatory processes of the synovial lining of the joint space. Even if the patient does not derive therapeutic benefit, the injection may help to provide diagnostic information about potential corrective surgery and in the best case scenario may help to preclude the need for more invasive surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient suffered from dementia, Alzheimers type, with significant impairment in cognition and ability to perform ADLs. The documentation noted that he was more calm and cooperative.  The records indicated that he was still resistive to care, but he was not aggressive.  This appeared to be his baseline, along with requiring 3:1 assistance to perform ADLs and 1:1 supervision.   Haldol was increased and the 1:1 supervision was discontinued.  Once this was done, the patient was pleasant, calmer, and cooperative.  He had one episode of agitation, requiring Haldol. However, this episode would not have necessitated ongoing inpatient hospitalization stay. Final Result: The reviewer determined that the services at issue was 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 geriatric 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for celecoxib (Celebrex) one tablet two times per day for treatment of the enrollees right shoulder and neck pain. Findings:  The physician reviewer found that in the documentation available for review, the patient has both gastrointestinal risks as well as cardiovascular risks. However, the records do not document that the provider has weighed the gastrointestinal and the cardiovascular risks in regards to choosing which pain medication is appropriate for this patient. The current medical literature shows that Celebrex is not the best non-steroidal anti-inflammatory drug (NSAID) for patients that have both gastrointestinal and cardiovascular risk factors. Also, there is a lack of documentation of how the patient responded to treatment with ibuprofen, physical therapy, and acetaminophen. Moreover, there is no report of other non-NSAID considerations, besides acetaminophen, for treating pain in this patient that has gastrointestinal and cardiovascular risks. The literature states that for patients at risk for cardiovascular and gastrointestinal events, NSAID therapy should be avoided. In the absence of such documentation, the requested Celebrex one tablet two times per day is not medically necessary for treatment of this patients medical condition. 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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stivarga. Findings:  Two of the three physician reviewers found that this patient has been treated with multiple modalities to control his osteosarcoma. The National Comprehensive Cancer Network guidelines note that there are several multi-agent chemotherapy regimens that can be used in this instance, and most of these regimens are off-label. Stivarga (regorafenib) is a multi-kinase inhibitor that has been approved by the U.S. Food and Drug Administration (FDA) for metastatic colorectal cancer, gastrointestinal stromal tumor, and hepatocellular carcinoma. A clinical trial demonstrated that regorafenib extended the progression-free survival compared to placebo. There is sufficient support for the requested medication for this patient who has exhausted other therapies. Therefore, Stivarga is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment 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 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 44-year-old male enrollee has requested osteochondral knee allograft procedure for treatment of his right knee osteochondral defect.  Findings:  Two physician reviewers found that based on the peer-reviewed medical literature, the requested procedure is likely to produce a superior health outcome for this patient compared to standard available therapies. Treatment of osteochondral defects with osteochondral allograft have been shown to be beneficial in various clinical studies in well selected patients (Levy, et al). The scientific data supports the use of osteochondral allograft in patients with a body mass index (BMI) of less than 35. The records demonstrate this patient has a BMI below the criteria. In addition, the documentation provides evidence that he has failed multiple conservative measures and has a documented focal lesion of the chondral surface of the patellar without opposing lesion on the trochlea. For these reasons, the requested osteochondral knee allograft procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the Wilderness Program services. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on this patients clinical history and documentation, at the time of admission to the program, the patient met CASII criteria for outpatient services. The integrative psychiatric notes reported that the patient was sleeping well, had good appetite, and had no suicidal or homicidal ideation. He was cooperative and friendly with a euthymic mood. There was no documentation of the patient endorsing severe depressive or anxiety symptoms, suicidal ideation or self-injurious behavior. There was no documentation of aggressive behavior towards others, impulsivity, or poor functioning while in the program. For these reasons, Wilderness Program services were not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in child and adolescent 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

The parent of a five-year-old female enrollee requested authorization and coverage of continued private speech therapy for the treatment of downs syndrom.  The health plan denied the enrollees request indicating that continued private speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested private speech therapy is medically necessary.