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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 150 mg/mL syringes (every 2 weeks, length of therapy/number of refills: 11, quantity: 2 per 28 days) for treatment of the enrollee who has a history of hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Praluent (alirocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  The documentation provided does not support a history of heterozygous familial hypercholesterolemia. This diagnosis requires not only elevated LDL cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism, according to published criteria. Based on the documentation provided, a diagnosis of heterozygous familial hyperlipidemia cannot be made by usual accepted criteria. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. For these reasons, Praluent 150 mg/mL syringes (every 2 weeks, length of therapy/number of refills: 11, quantity: 2 per 28 days). 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 cardiovascular disease 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 facial feminization surgeries. Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for review, including review of the photographs, the requested services are not medically necessary in this clinical setting. The midface and submental areas of this patient appear within the range of normal and not gender specific. Although this patient has documented gender dysphoria, the submitted photographs appear to support structures which are in the range of normal for her age and gender appearance as a female. Overall, the clinical documentation is insufficient to support the medical necessity of requested services. Therefore, facial feminization surgeries  are not medically necessary for the treatment of this patients gender dysphoria. With regards to whether the requested services are reconstructive in nature, the patient has an appearance that is within the range of normal and not necessarily gender specific. The patients condition does not constitute an abnormal structure of the body. The patients appearance is within the spectrum of female appearances with respect to the midface and submental areas. As such, the requested services appear consistent with aesthetic improvement, addressing appearance concerns and not specific gender related abnormalities. There is a wide spectrum of facial appearances that can be consistent with possible typical female appearances. Thus, this patients facial presentation is not considered an abnormal structure and the requested services are not expected to provide a more than minimal improvement in the patients appearance. For these reasons, facial feminization surgeries are not reconstructive in nature. 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 plastic 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: Upheld

A 61-year-old male enrollee has requested Sculptra injections  for treatment of his facial lipodystrophy secondary to medication.  Findings:  The physician reviewer found that the there is no evidence of a functional impairment that requires treatment with polylactic acid (Sculptra). Review of the submitted medical records reveals a lack of documentation of a loss of functioning secondary to HIV-associated lipoatrophy. The records provided do not demonstrate swallowing or gustatory malfunction, articulatory dysfunction or traumatic dysfunction of the oral cavity secondary to facial lipoatrophy. Thus, treatment with Sculptra for the patients HIV-associated lipoatrophy is not medically necessary to resolve or improve a functional deficit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech, language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in these patients. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach.Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the young patient has for developing adequate skills to function in the community. In the published literature, Most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions (Myers and colleagues). For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Children with autism have deficits in speech and language, as well as social interaction and pragmatic communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are the most appropriate providers. For these reasons, the requested speech therapy is medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy for evaluation of the enrollees Crohns disease, ulcer and diarrhea. Findings:  The physician reviewers found that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohns disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of patients based on findings missed by other tests. Capsule endoscopy is a valuable tool in evaluation of patients with Crohns disease and is more sensitive than conventional ileocolonoscopy for the diagnosis of small bowel Crohns disease activity. For these reasons, the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case, and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested diagnostic procedure is 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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 23-year-old male enrollee has requested for acute inpatient psychiatric services for treatment of his mood disorder, polysubstance dependence, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the American Psychiatric Association guidelines, patients should be treated in the least restrictive setting that is likely to be safe and effective.  the patient could have been treated safely and effectively at a lower level of care, such as the partial hospitalization program setting. The clinical notes do not reflect that the patient had failed to respond to, or was unable to access, services at a lower level of care.  Polysubstance users tend to have a higher percentage of comorbid psychiatric conditions which may enhance dysfunctional coping motives and interfere with treatment participation.  Treatment such as agonist therapies and cognitive behavioral therapy provide for better long-term outcome in this clinical setting.  These treatments could have been offered at the partial hospitalization program setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested a full body positron emission tomography (PET) scan for evaluation of her melanoma. Findings: Two physician reviewers found that National Comprehensive Cancer Network (NCCN) guidelines recommend the use of PET studies every 6 to 12 months for the first 5 years after treatment for melanoma. Other studies in the peer-reviewed medical literature also support the use of PET studies in the surveillance of patients with a history of melanoma. PET is superior for the detection of distant metastases in both the staging and surveillance of melanoma patients (Xing et al.). PET is more sensitive and specific than CT for detection of melanoma metastasis and should be considered the primary staging study for recurrent disease(Swetter et al.). FDG-PET is a metabolic, noninvasive imaging modality for detecting distant metastatic and recurrent melanoma (Kumar et al.). Additionally, when interpreted with a high threshold approach, PET demonstrates high accuracy for the diagnosis of both regional and distant disease in cutaneous malignant melanoma and frequently changes management in patients with stage II-IV disease referred for a variety of indications(Falk et al.). As there is more than adequate support in the peer-reviewed medical literature for the use of PET scans for surveillance of patients with melanoma for five years after treatment, the requested PET scan is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee, who has a history of gastroesophageal reflux disease (GERD), has requested authorization for the medication Nexium.Findings:  The physician reviewer found that the superiority of Nexium over other PPIs for patients such as this patient has not been demonstrated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Epclusa. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Epclusa is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld

The patient is a 22-year-old woman who was seen by a podiatrist for thickening, discoloration, and significant discomfort of her left first toenail. She was reportedly treated for nail fungus with nail debridement and topical antifungals in the past with modest improvement. Treatment options of nail avulsion, topical antifungals, and oral antifungals were discussed. The patient opted for topical treatment because she was concerned about side effects of oral antifungals. The patients provider has recommended Penlac for the patient. The Health Plan indicates the patient does not meet medical necessity criteria for authorization of Penlac.The Health Plans denial should be upheld at this time. The submitted information does not include a record of a microscopic exam for fungus or a fungus culture. If either test is performed and is positive, treatment with Penlac should be authorized. If a three-month trial of Penlac is ineffective, oral antifungals should be considered.  Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plan denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Findings: The physician reviewer found that in this clinical setting, a portion of the provider requested hours per week of ABA therapy, supervision and parent training is medically necessary for treatment of the patients autism. The patient has received high level ABA therapy since 2009. According to the documentation submitted for review, the patient has met some motor and language goals, but has not met many of the social goals. The patient continues to require a high level of ABA services due to his maladaptive behaviors that include aggression, non-compliance and whining. In addition, the progress reports show an increase in maladaptive behaviors. The Health Plans authorization of a reduced number of hours per week of ABA therapy is not clinically indicated for this patient. Decreasing ABA hours will likely lead to a return of previous behaviors and a loss of skills. Therefore, a portion of the requested hours per week of ABA therapy, supervision and training is medically necessary for treatment of the patients autism.Final Result: The reviewer determined that a portion of the requested services is 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 22-year-old female has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has a major depressive disorder.  Her symptoms include depressed mood, excessive sleep, suicidal ideation, lack of motivation, and anhedonia.  The patient has received inpatient psychiatric treatment.  The patient reported that her prior medications have included Depakote, Lexapro, Prozac, Cymbalta, Ritalin, and Wellbutrin.  Psychopharmacotherapy has not achieved remission.  The patients provider has recommended transcranial magnetic stimulation.  The current medical literature supports the requested transcranial magnetic stimulation in this patients case.  There is sufficient evidence in the published, peer-reviewed medical literature supporting the use of transcranial magnetic stimulation in this clinical setting. The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  This patient has failed to achieve remission with multiple medication trials.  Therefore, transcranial magnetic stimulation is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for skilled nursing facility level of care. The enrollee underwent a right total knee arthroplasty and entered a skilled nursing facility for rehabilitation. The enrollee required physical therapy and occupational therapy services to increase independence with gait, facilitate independence with all functional mobility, improve dynamic balance, increase functional activity tolerance and increase lower-extremity strength. This would enable the enrollee to return to her private residence with a reduced risk for falls and an ability to perform transfers with increased safety. Physical therapy notes show the enrollees bed mobility, transfer ability, and ability to climb stairs improved. Occupational therapy notes demonstrated a similar level of improvement.  The enrollee was also able to ambulate with a rolling walker with only stand-by assistance. Literature reports skilled nursing interventions greatly enhance an individuals functional ability, balance, transfer ability and performance of activities of daily living. Literature demonstrated that those who did not receive such interventions showed deterioration in these abilities.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 physical medicine and rehabilitation 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

A 46-year-old female enrollee has requested coverage for spinal fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that the patients pain has not been mechanical in nature and there is no evidence of standard indications for fusion such as spondylolysis, spondylolisthesis, instability, scoliosis, fracture, non-union from her previous fusion, or a tumor. Therefore, the patient does not meet accepted criteria, as established in the peer reviewed medical literature, for a lumbar fusion procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested 3 Lyme disease tests including ELISA, Western Blot and PCR and a consultation with an infectious disease specialist for evaluation of the enrollees facial and neck pain with numbness and paresthesias.  Findings:  The physician reviewer found that the patient has expressed concerns that he may have Lyme disease as an explanation for his symptoms of neck pain and spasms. These symptoms would be very unusual for Lyme disease. In fact, this patient has no recollection of a tick bite and has had no symptoms such as a rash or joint complaints that would support this diagnosis. In addition, two providers have suggested the patients symptoms change when his attention is diverted and that stress is a likely etiology for his complaints. Moreover, the patient has had a normal neurological assessment by several providers including a neurologist. The testing for Lyme disease was done correctly in this case. An ELISA screening test was done with negative results. According to the Centers for Disease Control (CDC), there is no need for additional testing when a screening test is negative. As noted by the CDC, The first step uses an ELISA or IFA test. These tests are designed to be very sensitive, meaning that almost everyone with Lyme disease, and some people who dont have Lyme disease, will test positive. The CDC indicates that if the ELISA or IFA is negative, it is highly unlikely the patient has Lyme disease, and no further testing is therefore indicated. As such, there is no need for an infectious diseases consultation or additional Lyme disease testing based on this patients symptoms, normal neurological examination, and negative Lyme ELISA test. For these reasons, the requested diagnostic testing and consultation services are not medically necessary for evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 41-year-old female with a prior history of varicose veins with removal, but no history of greater saphenous vein removal. The patient indicates she is now experiencing severe pain due to her varicose veins, which have been refractory to conservative treatment (i.e., stockings). The results of an ultrasound exam show bilateral greater saphenous vein reflux. The patients provider has recommended the patient undergo repeat vein stripping.Given these facts, radiofrequency ablation closure of greater saphenous veins with removal of painful varicose veins is clinically indicated and medically necessary. The patient has greater saphenous vein reflux, which is an anatomic deficiency. The standard of care for this symptomatic patient is vein stripping. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.