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 Repatha SureClick 140 mg/mL. Based on the records provided, the patient has hyperlipidemia with an LDL that remains above a goal of less than 70 mg/dL despite high dose atorvastatin and ezetimibe.  Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, there are several randomized prospective trials that demonstrate safety with adding PCSK9 inhibitors, significant additional reduction in LDL cholesterol and improved clinical outcomes. Therefore, the requested medication 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 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 Armour thyroid for treatment of the enrollees hypothyroidism.Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The treatment of choice for correction of hypothyroidism is synthetic thyroxine. The American Thyroid Association/American Association of Clinical Endocrinologists do not recommend the use of desiccated thyroid as replacement therapy for hypothyroidism.  In this case, the patient is requesting the use of Armour thyroid (desiccated thyroid) for the treatment of her condition of hypothyroidism.  There is no evidence that she has tried or had an adverse outcome to the synthetic thyroid medication, which is first line treatment.  Final Result: The reviewers 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 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 46-year-old female enrollee has requested an MRI for evaluation of her leaking silicone breast implant.  Findings:  The physician reviewer found that the presence of breast asymmetry and burning pain makes this patient symptomatic. Although MRI is a highly sensitive tool for diagnosing implant rupture in patients with capsular contracture, it has a low specificity and negative predictive value, which adversely affects its accuracy in this group of patients. A thorough clinical examination documenting symptoms, implant age, and degree of capsular contracture can be coupled with routine imaging studies, including mammogram and/or ultrasound, to diagnose silicone implant rupture as accurately as MRI. In this case, the symptoms, ultrasound findings and implant age are sufficient grounds for diagnosis of the patients left breast symptoms, so there is no need for an MRI. All told, in this patients case, the requested MRI is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested Prevacid for the treatment of her GERD. Findings:  The physician reviewer found that pharmocologic therapy for GERD continues to focus on optimizing acid suppression. Proton Pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continues to be the standard of therapy. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen. In this case, the patient should be given a trial of Protonix (single and double dose for eight weeks each), Aciphex (single and double dose for eight weeks), and Omeprazole (single and double dose for eight weeks) on the formulary. If she fails to respond to these trials, only then should she be approved for Prevacid.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested residential treatment center level of care services for treatment of her bulimia and depression.  Findings:  The physician reviewer found that based on a review of the records provided, the medical necessity for RTC level of care at the time of admission on the said date through discharge has not been established. The patient was in need of ongoing treatment for recurrent depression and a history of bulimia. However, applying the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria for RTC level of care, this patient was a candidate for treatment at a less restrictive level of care, specifically, intensive outpatient services. Further, the adult criteria for RTC level of care were not met. Consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychiatric Association (APA) treatment guidelines, this patient did not require the 24-hour direction and supervision provided at the RTC level of care during the period at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xifaxan for treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  This patient has irritable bowel syndrome with diarrhea (IBS-D).  The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has proven safe and effective in randomized placebo-controlled trials for IBS-D.  Although the patient has used Xifaxan before, clinical studies and the FDA approval do support use of Xifaxan again for two similar courses a specific period of time apart.  For these reasons, the requested Xifaxan 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha. The enrollee is a high risk patient and should be on maximal risk factor modification therapy including tight hypertension and diabetes control and aggressive lipid management. He is intolerant of multiple statins. Based on his medical condition, Repatha is reasonable and necessary for risk reduction use in this specific clinical situation, in accordance with published guidelines and with published data for improvement in clinical outcomes. 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 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

A 62-year-old female has requested Procrit (epoetin alfa) injections above 12 g/dL for treatment of her myelodysplastic syndrome.  Findings:  The physician reviewer found that although not currently listed as an indication by the Food and Drug Administration (FDA), the use of epoetin alfa injections has become standard of care for treating the anemia of myelodysplasia. As noted by Santini, et al. and Steensma, et al., a significant percentage of anemic patients respond to standard dose intramuscular injection and additional patients respond when the dose is increased. The drug is used to treat anemia and/or to render the patient transfusion independent (Balleari and Clavio). In the majority of cases of response, epoetin alfa injections were instituted for an Hb concentration of less than 10 g/dL and the Hb maintained between 10 and 12 g/dL (Balleari and Clavio). The rationale is that patients are anemic and usually symptomatic below 10 g/dL. The Hb of 12 g/dL is a normal level for women and in fact women qualify to donate blood at that level. An Hb of 12 g/dL is not anemic. There is no evidence that performance is enhanced by raising the hemoglobin above this level for people who do not live at extreme altitude, do not have deoxygenation from cardiopulmonary disease, or are not competitive endurance athletes. For that reason, patients are not generally maintained at an Hb greater than 12 g/dL, there is limited experience with such patients, and the adverse effects (if any) are unknown because of the lack of experience. The standard of care is to maintain the Hb between 10  12 g/dL. Therefore, the patients request for Procrit injections above 12 g/dL is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan. Current standards of practice recommend that patients with multiple sclerosis should be treated with a disease modifying therapy. Researchers noted that although one successful phase II trial reported positive results with Rituxan in treating patients with multiple sclerosis, the authors cautioned that the study had multiple limitations. Overall, there is a lack of clinical trials demonstrating the safety and efficacy of Rituxan in multiple sclerosis. Further, Rituxan is not U.S. Food and Drug Administration (FDA) approved for treatment of patients with multiple sclerosis. Moreover, the available data have not established that Rituxan is safer or more effective than standard multiple sclerosis therapies. In this case, the patient has been prescribed Rituxan as a disease modifying therapy for multiple sclerosis. This patient is noted to be treatment naive to disease modifying therapies that are considered within the standard of care for the treatment of multiple sclerosis. Therefore, the requested Rituxan is 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 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

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The current medical evidence indicates that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Children with untreated speech and language delay may be at risk for learning disabilities once they reach school age. Thus, speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial.  This patient has significant delays in speech and language that negatively impact his ability to express his needs and interact with peers and adults. Objective testing has demonstrated functioning overall at the 9 to 12 month level at a time when he was 31 months of age. It is also apparent from his evaluation that he has lost some skills (no longer points to body parts), and has poor social skills. The current medical evidence supports speech therapy in this clinical scenario.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested for IVIG therapy for treatment of her non-specific autoimmune disease and antiphospholipid antibody syndrome.   Findings:  Three physician reviewers found that IVIG remains controversial and/or investigational in the treatment of APS (antiphospholipid syndrome). The role of natural killer cells in recurrent miscarriage also is controversial or investigational. Its use outside of research protocols remains investigational.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an implanted infusion pump for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that an implanted infusion pump was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has progressive metastatic disease. Systemic opioids cause grogginess and severe constipation. The use of an implantable pump for this patient is standard care, medically appropriate, and consistent with current medical evidence. Moreover, a trial with an external pump is not required for the permanent placement of an intrathecal infusion pump. All told, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for residential treatment services and partial hospitalization program after treatment from the residential treatment facility. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is lack of support in the documentation for the medical necessity for the requested services in this clinical setting. The requested residential treatment center (RTC) level of care to treat psychosis is not considered within the standard of care. The note did not state that the patient had any suicidal or homicidal ideation or that she had command auditory hallucinations or that the patient required inpatient hospitalization. Although psychotherapy has been determined to be helpful for psychosis in schizophrenia, the standard of care treatment for psychosis is medication therapy. The patient was taking two medications at high doses but it is unclear how long the patient has been compliant with these medications. Per the documentation submitted, the patient had previously discontinued her medication. The records do not demonstrate that the patient is in imminent danger to herself or to others, or exhibits grave passive neglect to support inpatient psychiatric hospitalization. If the patient is in imminent danger to herself or others or exhibited grave passive neglect, then the patient would require inpatient psychiatric hospitalization. However, the documentation does not suggest that the patient requires inpatient psychiatric hospitalization. The patient would meet criteria for an intensive outpatient program to receive enhanced support during the week through psychotherapy as well as more frequent contact with a psychiatrist to adjust her medications to treat her medical condition. For these reasons, the requested residential treatment services and partial hospitalization program after treatment from the residential treatment facility have not been established as medically necessary for treating this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Urgent Care
Decision: Upheld

A 20-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. In the Emergency Department (ED), the patient was noted to have stable vital signs and no fever. The patients toe was swollen, painful and draining purulent fluid. The services provided were appropriate in terms of nail excision and antibiotics however the patient did not require emergent treatment for his condition. The patients condition was non-urgent and had been progressing for four weeks. At the time he presented to the ED, he had no fever or chills and could have been safely and adequately treated on an outpatient basis. All told, a layperson with this patients symptoms would not reasonably believe he was having an emergent medical condition such that his health would have been in jeopardy had he not obtained immediate medical services
Appeal type: Medical Necessity
Decision: Upheld

A 21- year-old male enrollee has requested  for residential substance abuse rehabilitation for treatment of his substance abuse.       Findings:  The physician reviewer found that the patient was found to be well groomed, cooperative, calm with a normal mood, appropriate affect, normal speech and  intact thought processes. There was no suicidality, or homicidality and no delusions or hallucinations. The patients judgment was intact, his insight was good, and he was alert and oriented to person, place and time. His cognition was good and his immediate, recent and remote memories were all intact. There were no signs or symptoms of withdrawal reported during his residential treatment stay. In fact, there was very little documentation describing the patients stay at the residential treatment center other than a written record of group attendance. The clinical record does not provide evidence that the patient required residential treatment or that his treatment could not have occurred at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee requested residential mental health and substance abuse treatment program services for medical treatment of her schizophrenia, anxiety disorder, and polysubstance abuse.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) dimensions, the patient does not meet the criteria for residential treatment. Given her history, psychotic features of her major depressive disorder, and poor sober support system, her potential for relapse supports the need for treatment at a lower level of care. While some progress was made, not enough was accomplished to warrant continued treatment at the residential level of care. For these reasons, residential mental health and substance abuse treatment program services were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested CT angiography (CTA for evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found CTA is not, thus far, a generally accepted screening or confirmatory test for the evaluation of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CTA would not be able to accurately confirm or exclude important coronary obstruction. The use of CTA in this clinical setting remains an experimental/investigational application of the technology.