Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser adalimumab (ADA) testing for evaluation of the enrollee who has a history of ulcerative colitis and intractable clostridium difficile colitis. Findings:  Two physician reviewers found that there is not currently sufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management this patients medical condition. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels.  It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Additionally, controlled studies are lacking to show that use of the test results in improved long term health outcomes for patients with ulcerative colitis compared with conventional management. Final Result: Two 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 internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Zomig for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients medical condition. While all triptans, intranasally administered or perorally administered work through the same mechanism, it is quite possible the intranasal sumatriptan may work in some patients when the oral formulation does not. The key is to administer it early enough during the development of the headache.  Thus, intranasal Imitrex should be trialed first and if it fails for this patient, then other triptans may be considered. Given the above, Zomig has not been established as medically necessary for treatment of the 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of suicide attempts, impulsive high-risk behaviors prior to admission to the RTC, and continued self-harm urges while at the RTC.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to serious deterioration of interpersonal interactions and conflict with her parents and brother, purging, deficits in self-care, and difficulty attending to activities of daily living. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to family conflict. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents participation in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to lack of improvement despite years of treatment at multiple levels of care.With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement in residential treatment due to her difficulty accepting responsibility and inconsistent participation in treatment.Thus, the patient has a total score of 21. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the RTC. Therefore, RTC services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested for 35 transcranial magnetic stimulation treatments for treatment of his major depressive disorder. Findings:  Two physician reviewers found that the peer-reviewed literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation.  Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality.  Their conclusions report that although results are suggestive that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are necessary to confirm these trends.   Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  In sum, the requested 35 transcranial magnetic stimulation treatments are not likely to be of greater benefit than other available treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda for treatment of the enrollees obesity. Findings:  The physician reviewer found that the main goal of a weight loss regimen should be to decrease a patients cardiovascular risk. Therefore, pharmacotherapy can be added to lifestyle interventions in patients with a BMI of 30 kg/m2 or greater regardless of health history or those with a BMI of more than 27 kg/m2 and one additional cardiovascular risk factor, such as diabetes, hypertension, or hyperlipidemia. The approval of Saxenda followed several randomized controlled trials demonstrating its safety and efficacy in obese or overweight patients. This patient meets the criteria for addition of an anti-obesity pharmacological agent. Her BMI is over, she has comorbidities including hyperlipidemia and edema and has not lost weight with diet modification alone. Treatment should be made available early in the disease to prevent irreparable complications. Her provider has recommended Saxenda, which is appropriate based on the progress notes provided for review. For these reasons, the requested Saxenda is medically necessary for treatment of this patients obesity. 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: Medical Necessity
Decision: Overturned

A fifty-nine year-old female diagnosed with multifocal motor neuropathy (MMN) is requesting approval for a course of IVIG. Reviewers Findings:  The reviewing physician found that there is strong evidence to support a diagnosis of MMN in this case. IVIG is recognized as the standard of care treatment of MMN.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries. Researchers acknowledge that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and, therefore, is much more medically necessary than for somebody without gender dysphoria. Researchers further state that although facial feminization procedures are generally labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Overall, FFS has been associated with improved mental health quality of life in transgender women who received the surgery, when compared with transgender women who have not undergone FFS procedures. This patient has undergone long-term care with at least four health care providers who support that she has gender dysphoria. These providers recommend FFS procedures to help alleviate the distress experienced related to her gender dysphoria. Therefore, the requested facial feminization surgeries are medically necessary for treatment of this patient. 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 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 nine-year-old female enrollee has for speech therapy for treatment of her central auditory processing disorder (CAPD).   Findings:  The physician reviewer found that this patient has a central auditory processing disorder. Despite this receptive language handicap, the patient has an above-normal intellect.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for proton beam radiation therapy (five times weekly for 39 treatments). A study was conducted to compare intensity modulated radiation therapy (IMRT) with proton beam radiation therapy to assess patient outcomes and toxicity. The study concluded that proton beam radiation was associated with a statistically significant reduction in genitourinary toxicity at six months compared with IMRT. This patient presents with prostate cancer with less than 30% of the core involved. In addition, the patients prostate specific antigen (PSA) has steadily risen over the past years. His provider has recommended treatment instead of surveillance given the rising PSA. Based on current medical literature, the requested proton beam radiation therapy is an appropriate intervention for this patient considering his age and increasing PSA. All told, the requested proton beam radiation therapy (five times weekly for 39 treatments) is medically necessary for treatment of this patient.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 urology 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 68-year-old male enrollee has requested Flector patches for the treatment of his condition. Findings:  The physician reviewer found that flector patches are topical non-steroidal anti-inflammatories.  They are typically utilized to control acute pain and inflammation associated with minor strains, spasms, and contusions.  These patches are not generally utilized, nor studied for, treatment of chronic pain due to reflex sympathetic dystrophy. Flector patches are not medically indicated for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization coverage for general anesthesia for treatment of the enrollees dental procedure (dental extraction).Findings:  The physician reviewer found that The request for general anesthesia service is not medically necessary for treatment of the patients medical condition. The medical literature cites rare but significant risks associated with any type of anesthesia, as well as treatment alternatives to general anesthesia. According to the medical records provided for review, the patient is a healthy 17-year-old with no medical indication for general anesthesia. Given that the patients physical examination does not demonstrate a clinical indication for general anesthesia, the requested general anesthesia is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has requested authorization and coverage for Korlym 300 mg for treatment of the enrollees Cushings syndrome. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  Cushings syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol. It is associated with poor quality of life, morbidity, and increased mortality.  While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery.  The U.S. Food and Drug Administration has approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome, who have type 2 diabetes or who have glucose intolerance and have not responded to or are not candidates for surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement (weight loss, decrease in glycemia and blood pressure, improvement in psychiatric symptoms) in the majority of Cushings syndrome patients. Moreover, the literature also suggests that mifepristone does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole. According to the submitted documentation, this patient is a good candidate for therapy with Korlym. Her Cushings syndrome is complicated by severe insulin resistance, which is complicating her diabetic control. All told, Korlym 300 mg is 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom continuous glucose monitoring device and supplies. Researchers note that continuous glucose monitoring systems (CGMS) enable patients to effectively control and adjust their insulin therapy. The author further notes that while use of CGMS may not significantly reduce the number of severe hypoglycemic episodes, recent data indicate that they may reduce the time spent in hypoglycemia. In this case, a CGMS is medically indicated for this patient to improve her glycemic control and prevent diabetic complications. Therefore, Dexcom continuous glucose monitoring device and supplies are medically necessary for the treatment of this patient.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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested liver elastography for evaluation of her hepatitis C.  Findings:  Three physician reviewers found that the liver elastography performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Elastography is widely-accepted as a community-recognized non-invasive test of choice when liver biopsy is undesired. The technique demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis, as well as in correlating treatment response in patients such as in this case with chronic hepatitis C infection. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his Ewings sarcoma. Findings:  Three physician reviewers found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the medical records provided for review, the patient presents with Ewings sarcoma and in this clinical setting IMRT is likely to be the most effective way to treat this patient and spare the surrounding normal tissues. In addition, the scalp is a complex shaped volume for which IMRT is well-suited. IMRT is expected to improve the dose coverage and dose homogeneity. For the reasons provided, IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee requested for skilled nursing care  for treatment of his Fanconi Syndrome and osteomalacia with multiple skeletal fractures. Findings:  The physician reviewer found that the occupational therapy records also show progress towards minimal assistance. The patient had not reached his potential, and he had not reached a plateau.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 6-year-old male enrollee has requested for ultraviolet home therapy lamp for treatment of the enrollees vitiligo.  Findings:  Two physician reviewers found that the medical literature, El-Mofty and colleagues concluded that, broadband UVA alone, without psoralens, and in appropriate doses may be of important therapeutic value in vitiligo. The device provided this patient is the National Biological Dermalight instrument which is equipped with a lamp emitting UVA light. Since the use of UVA light is supported in the clinical studies as a treatment option for vitiligo when first-line therapies fail, its use is likely to provide this patient more benefit than standard therapeutic alternatives.