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

Findings:  The physician reviewer found that The enrollee has requested authorization and coverage for the medication Wegovy.Semaglutide is an anti-diabetic agent, glucagon-like peptide-1 (GLP-1) receptor agonist. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention which includes a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. Wegovy and Ozempic are brand names for semaglutide. Wegovy is a brand name form of semaglutide that is indicated for chronic management of obesity. Wegovy has been approved by the United States Food and Drug Administration (FDA) for use as an adjunct to diet and exercise in individuals with a BMI greater than 30 kg/m2 or for individuals with a BMI greater than 27 kg/m2 and one or more weight-associated comorbidities. In this case, the submitted documentation supports that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. The patient has a BMI that is greater than 30kg/m2 and has had good past results with the requested medication. Under these circumstances, the requested medication Wegovy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested authorization and coverage for continued acute inpatient rehabilitation services for treatment of the enrollees medical condition status post hypoxic ischemic brain injury.  Findings:  The physician reviewer found that based on review of the available records, the patient requires contact guard to stand by assistance for bed mobility, transfers, and ambulation of up to 80 feet. He has stabilized at this level of care although his endurance can continue to improve. Similarly, he has stabilized at minimum assistance for grooming and dressing. He does require moderate assistance for bathing. The medical literature does not support continued daily inpatient skilled therapy at three months following the critical event. He has made gains that allow his needs to be addressed at a lower level of care and additional gains do not require daily inpatient therapy. All told, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for weekly individual therapy sessions and year-long dialectical behavior therapy (DBT) group therapy for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the records reflect the fact that the patient has symptoms consistent with borderline personality disorder and has recently expressed suicidal ideation. The records appear to indicate the patient has been seen by her psychiatrist recently who has recommended psychotherapy for her condition. It is not clear from the records when the last time the patient has attempted a full course of DBT. The standard of care for DBT includes individual and group therapy for approximately one year.  Borderline personality disorder can be a very recalcitrant illness. One of the mainstays of treatment for borderline personality disorder is DBT, which can occur in a less restrictive setting once patients are free from safety concerns, which was the case for this patient.  This therapy is effective for borderline personality disorder and is provided in the outpatient setting on a regular basis. Due to the fact that borderline personality disorder tends to be difficult to treat, it is possible that individuals with this condition may need multiple trials of therapy for multiple years. The records indicated that the patients apparent functional impairment problems are due to her borderline personality disorder. In sum, weekly individual therapy sessions and year-long DBT group therapy is medically necessary for the 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the STAR program for treatment of the enrollees sensory processing disorder.  Findings:  Two physician reviewers found that the American Academy of Pediatrics (AAP) released a policy statement for sensory integration therapies for children with developmental and behavioral disorders. The AAP states that it is unclear whether children who present with sensory-based problems have an actual disorder of the sensory pathways or whether these deficits are associated with other developmental and behavioral disorders. The AAP notes that because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. According to the AAP, occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In addition, Researchers conducted a systematic analysis on the outcomes of 17 single case design studies on sensory integration therapy (SIT) for people with, or at risk of, a developmental or learning disability, disorder or delay. The authors noted that SIT is a controversial intervention that is widely used for people with disabilities. An assessment of the quality of methodology of the studies found most used weak designs and poor methodology. The authors concluded that based on limited comparative evidence, functional analysis-based interventions for challenging behavior were more effective that SIT. The authors further stated that the studies did not provide convincing evidence for the efficacy of SIT. Given the lack of support in the peer-reviewed literature, the STAR program has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1 is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Reviewers 2 and 3 are board certified in pediatrics and neurology with special qualification in child neurology 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:  An enrollee has requested separate anesthesia services during a colonoscopy for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Monitored anesthesia care (MAC) services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. According to the documentation submitted for review, there were no specific circumstances in this case that warranted MAC anesthesia. In this case, the patient could have been sedated by the gastroenterologist using a short-acting narcotic and benzodiazepine. Based on the documentation submitted for review and the peer-reviewed literature, the services at issue were not medically necessary for treatment of the patients medical condition.  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 internal medicine with sub-specialty 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: Overturned

A 32-year-old female enrollee requested percutaneous patent foramen ovale closure for treatment of her patent foramen ovale.  Findings:  Three physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other available treatment options.  The current medical evidence supports the requested percutaneous patent foramen ovale closure in this clinical setting.  This patient had a stroke in the postpartum period, and the record documents plans for future pregnancies.  At 32 years of age, she is likely to need anticoagulants for several decades.  Given this patients clinical history, the requested percutaneous patent foramen ovale closure is likely to be superior over other available therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for an oscillatory chest clearance system (Vest system) for treatment of her cystic fibrosis.   Findings:  The physician reviewer found that the Vest system was approved by the U.S. Food and Drug Administration in 1988.  It has been used widely for more than a decade. There are a number of studies looking at the quantity of sputum produced in response to manual chest percussion compared to other techniques of pulmonary toilet. Data regarding long-term use of high frequency chest wall oscillation in patients with cystic fibrosis demonstrates improved maintenance of lung function in children using chest wall oscillation compared to manual percussion. Whether this effect is due to enhanced compliance or superiority of the technique is immaterial, as the goal of pulmonary toilet is to maintain pulmonary health, and the outcome in this study is preservation of lung function as measured by pulmonary function testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg twice daily. This patients alopecia areata has not improved with first-line steroid injections. Over the last six months, his hair loss has rapidly progressed to include more than 50% of his scalp and his beard. For rapidly progressing alopecia areata, oral Xeljanz 5 mg twice daily is an excellent choice for the next step on the treatment ladder. A substantial volume of peer-reviewed literature supports treatment with Xeljanz in this patients clinical setting. Liu and colleagues studied Xeljanz in 90 patients with severe alopecia areata and found a clinical response in 77% of patients with no serious adverse events. Similarly, Cheng and colleagues demonstrated success in alopecia areata patients with Xeljanz. Jabbari and colleagues studied Xeljanz in moderate to severe patch-type alopecia areata. The authors noted that only one of 12 patients did not respond with regrowth. Since standard therapies have not substantially improved this patients condition, treatment with Xeljanz is indicated. Therefore, the requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg twice daily is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in dermatology with subspecialty certification in dermatopathology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology with subspecialty certification in dermatopathology 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 an office visit (CPT code 99205) with an infertility specialist. Findings:  The physician reviewer found that The American Society for Reproductive Medicine defines infertility is a disease historically defined by the failure to achieve a successful pregnancy after twelve months or more of appropriate, timed, unprotected intercourse or therapeutic donor insemination. The definition notes that earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35, or after the failure of six cycles of donor insemination due to the associated lower cycle fecundity. In this case, given that the records do not document a failure to conceive with proper sperm exposure and do not document an impairment that will prevent the patient from conceiving upon exposure to sperm, the requested services are not medically indicated. Therefore, an office visit (CPT code 99205) with an infertility specialist is not medically necessary for the treatment of this patient.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 upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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 45-year-old male enrollee requested authorization and coverage of a sleep study. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female has requested the brand name prescription Anafranil for treatment of obsessive compulsive disorder.  Findings:  The physician reviewer found that Anafranil is a brand name medication that falls within the tricyclic antidepressant class.  Due to its particularly potent serotonergic properties, this medication remains one of the well-trusted interventions in the treatment of obsessive compulsive disorder.  The generic equivalent to this brand name medication is clomipramine.  It is relevant to consider that nearly 80% of medications dispensed in the United States are generic preparations.  This common practice is supported by United States Food and Drug Administration bioequivalence testing that ensures that the generic product performs the same as its respective brand name product.  In some cases, a particular preparation, either brand name or a specific generic, may be necessary due to tolerability and efficacy reasons.  However, the submitted documentation fails to demonstrate the medical necessity of the requested brand name medication in this patients case.  Although the patient reported poor tolerability, there is no evidence in the medical records that she has had a change in clinical status due to the generic equivalent.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nintedanib (OFEV). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic pulmonary fibrosis.Findings:  Ofev (nintedanib) is U.S. Food and Drug Administration approved and its use in this clinical setting is supported by the medical literature to delay disease progression. Published medical literature indicates, Nintedanib, a receptor blocker for multiple tyrosine kinases that mediate elaboration of fibrogenic growth factors (e.g., platelet-derived growth factor, vascular endothelial growth factor, fibroblast growth factor), appears to slow the rate of disease progression in IPF In clinical trials, the main benefit of nintedanib is a reduction in the rate of decline in lung function. In this patients case, he meets criteria for treatment with Ofev (nintedanib) with documented decline in his functional status. The requested medication delays the rate of disease progression in patients who are diagnosed with IPF. This patient has had a decline in his lung function and could benefit from treatment with the requested medication. Accordingly, Ofev (nintedanib) has been demonstrated as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer has 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 pulmonary 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sclerotherapy. Current Society for Vascular Surgery (SVS) and American Venous Forum (AVF) guidelines recommend compression therapy as the primary treatment to aid healing of venous ulceration. The guidelines also support phlebectomy or sclerotherapy to treat varicose tributariesand suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein. A review from medical literature demonstrates that the available clinical trial evidence suggests that endovenous thermal ablation should be preferred to surgery and foam sclerotherapy in the treatment of GSV and small saphenous vein (SSV) incompetence. The prevalence of tributary reflux alone is present in about 10% of patients and most have CEAP 2 and 3 symptoms. Following GSV ablation, persistent non-refluxing branches do not appear to have an adverse impact on clinical outcome one year after successful ablation of the GSV. There is insufficient clinical data to recommend ablation of the non-axial veins. This patient is status post radiofrequency ablation on the left GSV. The records document failure of compression therapy. She currently presents with bilateral symptomatic varicose veins. The left leg residual varicose veins are suitable for injection sclerotherapy. There is evidence to support sclerotherapy in the treatment of accessory recurrent varicose veins following radiofrequency ablation. However, the records do not support treatment with sclerotherapy for the right leg. The current medical literature support endovenous thermal ablation in the treatment of GSV incompetence. Therefore, left leg sclerotherapy is medically necessary for the patients accessory recurrent varicose veins. Final Result: The reviewer determined that a portion of the requested services are 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 surgery with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested radiofrequency ablation for treatment of her sacroiliac joint pain and inflammation.  Findings:  Three physician reviewers found that this patient has been diagnosed with left SI joint pain by two providers. She underwent diagnostic blocks on occasions with significant improvement which confirmed the diagnosis. Subsequently, she underwent radiofrequency neurotomy, which provided her with good pain relief and improvement in functional status. Radiofrequency neurotomy to manage SI joint pain after appropriate diagnosis is an emerging concept (Manchikanti, et al; Falco, et al). Overall, there is adequate literature with two randomized, controlled trials, showing positive results with cooled radiofrequency neurotomy in this patient population (Cohen, et al). Thus, treatment with radiofrequency neurotomy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.