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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. According to the most recent joint guidelines, 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 Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. All told, Mavyret 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense breast tissue.  The advantage relates to the ability to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional technique alone. 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 reviewers are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested Nutropin growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests with a height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile, a growth velocity less than the 25th percentile for bone age, a bone age more than 2 SDs below the mean for age, low serum IGF-1 and/or IGFBP-3, or other clinical features suggestive of GH deficiency. This patient does not meet these criteria. Based on the delayed bone age radiograph of 13-years at a chronological age of 14-years, 3-months, and a concomitant height measurement of 146 cm, the estimated final adult height prediction is approximately 65 inches using the Bayley-Pinneau method and assuming a normal growth velocity. This adult predicted height falls within an appropriate range for the patients genetic potential. Further, as his predicted adult height is taller than 63 inches, he is not short enough to qualify for a trial of GH therapy on the basis of the FDA-approved indication of idiopathic short stature. Of import is that his height is not more than 2.25 SDs below normal for age and gender and there is no documentation of abnormally low growth velocity prior to GH treatment. In addition, his IGF-1 level is normal, he has not failed 2 provocative GH tests, and he has no known morphological abnormalities of his pituitary gland. As such, the requested Nutropin GH therapy has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a cortisone injection for treatment of the enrollees inguinodynia. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services. There is no contraindication to performing a steroid injection prior to surgery. The medical evidence supports performing the injection using ultrasound guidance to assure precision placement. Colleagues have suggested a stepwise approach which includes steroid injections. A steroid injection does not preclude surgery. There is no indication that surgery should be delayed after steroid injection. The medical evidence supports the requested services in this clinical setting. All told, the requested cortisone injection 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 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: Medical Necessity
Decision: Upheld

The representative of a 61-year-old female enrollee has requested acute rehabilitation care for treatment of her medical condition status post cerebrovascular accident (CVA).  Findings:  The physician reviewer found that the focus of acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time due to the natural recovery process but are also amenable to rehabilitation interventions (Turner-Stokes, et al). The role of inpatient rehabilitative care for persons with significant post-stroke functional deficits is relatively well-established in the medical literature (Langhorne, et al.).In the present case, the patient sustained an acute cerebral stroke with severe functional deficits. Despite a prolonged period of inpatient care and rehabilitation, she still had severe functional deficits at the time she was transferred to acute inpatient rehabilitation on the date in question. In addition, she continued to have severe cognitive impairments. She made some modest gains while in acute inpatient rehabilitation but less than a month later, the patient could have been treated in a less intense level of rehabilitative care. Without any expectation of significant improvement in health or functional outcomes with ongoing acute inpatient rehabilitation in comparison to services provided at a less intense level of care, the services provided during the timeframe were primarily for the convenience of the patient and family until transfer could be effectuated to a lower level of care in another state. For these reasons, the medical necessity of the services at issue has not been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee requested bariatric surgery (Lap-Band for treatment of her obesity.  Findings:  Three physician reviewers found that the patient has a medical history of hypertension, type 2 diabetes, hyperlipidemia, and nonalcoholic steatohepatitis (NASH).  The patient reports that her body mass index has fluctuated between 30 and 34.  The patient is 57.5 and weighed 203 pounds on a recent weigh-in, resulting in body mass index of 31.32.  She has attempted a variety of self-directed interventions to facilitate weight loss, and she has not been successful at long-term weight reduction.  The patient was entered into a clinical trial for two years.  This was an observational study of etiologies related to NASH development and included dietary counseling, exercise diaries and medical review.  The documentation does not indicate that this included dietary or exercise interventions.  The patients provider has recommended bariatric surgery (Lap-Band).  The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.  In this patients case, the requested procedure is not likely to be more effective than other methods of treatment.  She does not meet the National Institutes of Health criteria for bariatric surgery for the treatment of her obesity.  Although the patient reported a variety of attempts at weight loss, the documentation does not demonstrate that these attempts at weight loss have been medically directed.  Thus, the patient has not failed non-surgical attempts at weight loss.  All told, the requested bariatric surgery (Lap-Band) is not likely to be of greater benefit than other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested for Provigil for treatment of her excessive daytime fatigue and hypersomnolence. Findings:  The physician reviewer found that obstructive sleep apnea refractory to CPAP is an approved indication for Provigil. In this case, the patients obstructive sleep apnea is refractory to CPAP secondary to claustrophobia. Thus, CPAP therapy is not a viable alternative to control the patients daytime somnolence. A medical condition may be refractory to therapy for numerous reasons, including as this case illustrates, psychological limitation, mainly claustrophobia.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rybelsus tablets. Findings: As noted in the peer-reviewed medical literature, glucagon-like peptide 1 (GLP-1)-based therapies represent a significant advance in the treatment of patients with diabetes. When compared with placebo, all GLP-1 receptor agonist use reduced hemoglobin A1C by approximately 1-1.2%. Recently, GLP-1 analogs have become available in oral rather than injectable formulations. The U.S. Food and Drug Administration (FDA) has approved Rybelsus as the first oral GLP-1 analog for the treatment of adults with type 2 diabetes. Recent trials have demonstrated that Rybelsus can produce results similar to the subcutaneous formulation. This patient reported that her obesity and prediabetes have benefited with use of Rybelsus. However, the records do not document a diagnosis of diabetes to support an indication for treatment with Rybelsus. Therefore, the requested Rybelsus tablets are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old female enrollee has requested  for growth hormone therapy (GH) therapy with Somatropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient appears to have constitutional delay on a background of familial short stature. According to the Greulich and Pyle tables, she is on track for an adult height exceeding the mid-parental height and does not require GH therapy to achieve this.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested intensive outpatient program for treatment of the enrollees substance use disorder.  Findings:  The physician reviewer found that the patients mental status examination (MSE) reveals no major mood disturbance, anxiety, suicidal ideation, or psychosis. The patients progress notes indicate he was having a good week in school and was following his home contract. The provider indicated the patient was doing well in school and attending meetings. It should be noted that his urine drug screens were negative. Based on the Child and Adolescent Level of Care Utilization system (CALOCUS) and the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines, this patient was a candidate for less restrictive level of care. Given that he was involved in his treatment and was at low risk for relapse, he was a candidate for community based services during the period at issue. For these reasons, the medical necessity for IOP has not been demonstrated based on the records provided.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested residential inpatient rehabilitation services for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the records indicate that this patient was motivated for recovery and had a supportive family.  He was actively engaged in treatment.  The patient did not demonstrate any behavioral dysregulation.  He had no psychiatric or medical comorbidity.  All told, residential inpatient rehabilitation services were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil. Fatigue is a common symptom of patients with multiple sclerosis (MS), and may be disabling, limiting daily activity and communication, and greatly impacting quality of life. Toosy and colleagues report that management of MS symptoms may be challenging due to their interacting with each other, and that the evidence base for the management of MS symptoms with pharmacologic therapies is not strong due to the challenges of clinical trials in identifying symptomatic therapies. In a meta-analysis, Shangyan and colleagues evaluated the efficacy of modafinil versus placebo in the treatment of MS fatigue, including double-blind, randomized controlled trials. The authors concluded that modafinil was superior to placebo and was an effective pharmacologic therapy for MS fatigue. In this case, the patient has fatigue associated with MS. Given that the records note that the patients fatigue has been managed with modafinil, the requested medication is medically indicated. Therefore, modafinil is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. While 4Kscore testing may add a level of statistical support for a noninvasive estimation of the presence of prostate cancer, its benefit to individual patient care decisions over isolated PSA monitoring has yet to be demonstrated. The medical evidence has not demonstrated the superior efficacy of 4Kscore testing over standard of care for patients with elevated PSA. In sum, laboratory testing was not likely to have been more effective than other available methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in urology 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: Overturned

A 29-year-old male enrollee has requested for Botox injections for treatment of his hyperhidrosis. Findings:  The physician reviewer found that Botox is the newest therapy that does provide significant improvement of symptoms in many patients.  The above list of references supports the effectiveness of Botox in management of palmar hyperhidrosis.  Palmar hyperhidrosis can be debilitating as it interferes with a persons ability to use their hands for routine activities as well as for job-related activities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three reviewers found that the breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening.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 diagnostic radiology 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Lyrica 150 mg capsules. In the medical literature, van den Beukel and colleagues performed a systematic review of abdominal pain treatment options in patients with adhesions-related chronic abdominal and pelvic pain after surgery. The authors concluded that in a trial of 18 patients, Lyrica tended to have benefit over placebo improving pain at three months. Silverman and colleagues performed a double-blind, placebo-controlled trial to evaluate the efficacy of Lyrica on pain modulation in patients with prior abdominal surgery and documented adhesion. The authors concluded that Lyrica significantly reduced patient-documented pain scores compared with placebo in our small cohort of patients with abdominal adhesion pain. In this case, the patient has chronic abdominal pain due to initial gunshot wound status post small bowel resection with multiple abdominal surgeries complicated by recent hospitalization for small bowel obstruction. The provider reports that the patient has been stable on Lyrica, which is being using in combination with Norco for pain relief. The patient has not reported any side effects or adverse drug reactions. Moreover, the patient indicated that this treatment regimen improves fatigue and ability to function. The patient has previously been treated with numerous other medications from different drug classes without substantial benefit. The patient has expressed an interest in weaning off  chronic opioid therapy which has been ineffective, and the provider has recommended a trial of increased dose of Lyrica. In this clinical setting, there is adequate data to support an increased dose of Lyrica for this patient to address the patient's ongoing abdominal pain. Based on the medical records and current literature, the requested Lyrica 150 mg capsules are 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100-40 mg. The Health Plan has denied this request indicating that the medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2b. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg is medically necessary for 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.