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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wipes.Researchers state that risk factors for development of incontinence-associated dermatitis include compromised skin (e.g., due to aging, steroid use or local trauma/friction), immobility, decreased cognitive awareness, inability to perform personal hygiene, pyrexia, and poor nutritional status. Due to a lack of high quality experimental literature, prevention and treatment of incontinence-associated dermatitis is largely guided by expert opinion and focused on addressing the incontinence itself when feasible, timely clean up following incontinent episodes, and applying skin protectants, such as barrier creams. With respect to specific cleansing products and techniques, traditional soap (which has an alkaline pH) and water are generally considered poorly effective in preventing and treating incontinence-associated dermatitis. Researchers state that healthy skin has a pH of approximately 5-5.5 and the use of alkaline products has been observed to promote an environment that favors bacterial growth. Researchers state that experts have recommended the use of bath or shower oils without allergens or pH-neutral cleansing foams applied on soft, single-use cloths for a gentle cleansing of the skin, followed by simple patting with an absorbent towel to avoid the friction damage associated with rubbing. Regular application of a thin layer of a hydrating barrier cream optimized for the individuals skin and circumstances is also recommended as a consideration. In this case, there is no specific need for the Prevail Adult Washcloths in question, which are disposable cloths infused with a blend of lotions containing aloe and vitamins. The item in question is a convenience item used for bodily hygiene that combines disposable wipes with lotions, which are otherwise readily commercially available for routine bodily hygiene. Thus, the requested wipes are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested supplies 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for inpatient hospital services for treatment of her bipolar disorder. Findings:  The physician reviewer found that the time of admission there was uncertainty regarding whether the patients diagnosis was unipolar versus bipolar, and the patient had placed a bag over her head the previous night. There was also a past history of another suicide attempt, and ongoing outpatient treatment was no longer effective in dealing with her depression.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eleven-year-old female enrollee has requested Applied Behavioral Analysis (ABA) for the treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA is more beneficial than standard autistic treatments and is now considered a non-investigational mainstream therapy. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings, including the home, school and community. ABA-based interventions have been very well-documented. More recently, a review of the state of the science for pediatric primary health care clinicians on autism (Asch. Pediat. Adolesc. Med/Vol 160, Nov 2001) claims ABA is superior to other intervention strategies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Tecfidera for treatment of her multiple sclerosis. Findings: Three physician reviewers found that in this case, this patient had previously been treated with Tecfidera for an extended period of time with no relapses or evidence of disease activity, and no reported adverse events. When the patient was switched to a therapy that required the use of injections, she was not compliant because of her fear of needles and therefore, therapies requiring the use of needles have not been proven to be effective for the patient. Tecfidera is a U.S. Food and Drug Administration (FDA) approved medication for relapsing forms of MS. Given the patients previous successful use of Tecfidera with good disease control and manageable side effects, the requested medication for treatment of this patients MS is likely to be more beneficial than the available formulary or any standard alternatives.  Final Result: Three 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: All three physician reviewers are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested Remicade IV infusion for the treatment of her sarcoidosis. Findings:  Two physician reviewers found that this patient's recent biopsy confirmed sarcoidosis in the left thumb. It appears she has not had adequate response to prednisone, which is first-line therapy. Conventional therapy in this setting would include a trial of immunosuppressant therapy, such as methotrexate, as the next appropriate step. There is no evidence to suggest that Remicade, a TNF antagonist, is more efficacious for sarcoidosis than immunosuppressant agents. Therefore, a trial of Remicade is not indicated for this patient until attempts at more conservative therapies have been exhausted.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested for Norditropin NordiFlex for treatment of the enrollees stated diagnosis of isolated growth hormone deficiency. Findings:  The physician reviewer found that while he has been experiencing declining growth rate, this could be related to his pubertal delay. This patients growth hormone dependent IGF-1 level was normal for gender and stage of development. His mid-parental height expectation is 59.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature and DiGeorge syndrome.  Findings:  The physician reviewer found that in a study analyzing 61 patients with DiGeorge syndrome to determine the frequency of endocrine abnormalities in this population, Choi and colleagues reported that 16% of patients were below the 3rd percentile in height, but serum IGF-1 level was normal in 9 of 10 of these patients. Further, GH deficiency is not commonly seen in association with DiGeorge syndrome. All told, other causes of short stature have not been ruled out prior to considering a trial of GH therapy. Therefore, the requested therapy is not supported as medically necessary for treatment of this patients medical condition based on the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested residential level of care for treatment of the enrollees bipolar disorder, mixed, without psychotic features, attention deficit/hyperactivity disorder, oppositional defiant disorder, marijuana dependence and alcohol abuse.  Findings:  The physician reviewer found that in this patients case, residential level of care from the date in question forward was not and is not medically necessary.  The patient was cooperative, and there is no documentation of any behavioral issues which warranted containment on a 24-hour basis. There is no indication of serious risk to self or others. The progress notes submitted showed that the patient received on average no more than one hour per day of active programming.  He did well in his classes, and there were no medication changes during the course of his stay.  The intensity of services rendered was not commensurate with that expected in a residential facility.  He could have been safely and effectively managed in the context of outpatient therapy. Therefore, outpatient therapy was medically necessary for the treatment of this patient.  The review by Wilmshurst provides evidence that residential treatment is not more effective and may in fact be less effective than services rendered in the community. Finally, American Psychiatric Association standards indicate that patients should be treated in the least restrictive setting which is likely to prove safe and effective. The data reviewed do not establish that this setting was the least restrictive one in which the treatment could have been reasonably provided.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old man with mandibular hypoplasia. The treating oral surgeon indicates there is no functional contact of the anterior dentition and therefore, a satisfactory result for correction cannot be obtained by orthodontic treatment. The submitted materials include the following measurements: overjet-6mm and overbite 5-6mm. A request has been made for bilateral ramus osteotomies. The Health Plan indicates that the requested procedure is not medically indicated. While the information submitted by the patients surgeon indicates a significant dental occlusal discrepancy, this alone does not constitute a health or medical problem. Many people are tolerant of this type of dental malocclusion. No disability or discomfort has been documented by the patients providers. Given the absence of documented symptomatology resulting from the malocclusion, the requested procedure is not medically indicated. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested a fingertip prosthesis for the treatment of her status post left small fingertip amputation. Findings:  The physician reviewer found that the medical literature indicates that digital prostheses can provide significant functional benefit in cases where there is evidence of impaired functionality. In this case, there is no documented evidence of impairment. The patients physician describes normal hand function. The physicians notes document full range of motion in the digit, no pain, and a normal gripping ability. The physician further indicates that the patient requests a finger prosthesis for cosmetic reasons only. In the absence of objective documentation of a functional problem, the medical necessity of the proposed fingertip prosthesis is not established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injection.  Findings:  The physician reviewer found that  the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has lumbar radiculopathy, and the probable etiology is either scaring or recurrent disc protrusion at the site of the prior laminectomy.  However, the records do not document that he has had a recent trial of conservative therapy.  The American Pain Society recommends a trial of conservative therapy before starting interventional therapy.  Conservative therapy includes physical therapy, chiropractic therapy or a home exercise program.  All told, the requested lumbar/sacral transforaminal epidural injection is not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) suggests that tomosynthesis be removed from investigational status, due to the advantage the new technique brings to radiologists in the detection of breast cancer. The tomographic nature of this technique often allows the radiologist to separate dense glandular elements from underlying architectural distortion resulting in a decrease in call-backs and increase in detection of small cancers. In sum, the addition of tomosynthesis to two-dimensional (2D) imaging is likely of more benefit to the patient than 2D mammography without tomosynthesis. Final Result: Two 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

A 41-year-old female has requested coverage for a bariatric surgery consultation for treatment of her obesity.  Findings:  The physician reviewer found that applying the treatment guidelines from the National Institutes of Health (NIH), this patients records do not document morbid or clinically severe obesity. Thus, although the patient is obese with a BMI of greater than 35 but less than 40, she does not have documented evidence of any serious weight related co-morbid conditions such as diabetes, hypertension or sleep apnea. For these reasons, the requested surgical consultation has not been shown to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Xiaflex for medical treatment of his Peyronies disease. Findings:  The physician reviewer found that Xiaflex is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. Moreover, Xiaflex is the only FDA approved drug for Peyronies disease. This patient has failed conservative therapy and is an appropriate candidate for Xiaflex given the presence of penile plaque, 50 degree penile curvature, and pain with erections. All told, the medical records support the requested Xiaflex injections as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested liposuction of the abdomen, thighs and/or buttocks for treatment of her lipodystrophy. Findings: The physician reviewer found that based on the records provided, the patients condition would not constitute an abnormal structure of the body. Further, the recommended liposuction is being requested to improve the patients appearance, but there is no documentation in the records provided for review that demonstrate the patient has functional impairment as a result of the fat accumulation. The patient reports that she does not want to swim in public due to her condition, but no mention of trial and failure of conservative measures have been provided. Since the requested surgery would not improve the patients function, and would only offer a minor improvement in her appearance, the surgery has not been established as reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Dupixent. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The patient has requested coverage for Dupixent for the treatment of severe atopic dermatitis. Per the records, the patient has been treated with topical steroids, calcineurin inhibitors, and oral antihistamines, without relief. The Health Plan is requiring the treatment with phototherapy (UVB or PUVA), or systemic treatment (for example, corticosteroid or immunosuppressants). It is reasonable to require that the patient trail and fails therapy with ultraviolet light or systemic immunosuppressants prior to approving Dupixent. The medical evidence does not support the requested medication in this clinical setting. Therefore, Dupixent is not medically necessary for the 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 dermatology 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 Xultophy 100-3.6 100 unit-3.6 mg/mL (3 mL) insulin pen. The records provided for review document that this patient has type 2 diabetes mellitus that has not been adequately controlled with multiple diabetic agents including glucagon-like peptide 1 (GLP-1) and basal insulins. The patient has since been started on Xultophy and is tolerating the medication well with improvement in his glycemic control. Xultophy is a combination of insulin degludec and liraglutide that has been U.S. Food and Drug Administration (FDA) approved to improve glycemic control in patients with type 2 diabetes as an adjunct to diet and exercise. Based on this patients failure to respond to multiple diabetic agents, Xultophy is consistent with the recommendations from the American Diabetes Association (ADA). Continued treatment with Xultophy is important to help this patient maintain adequate glycemic control. All told, the requested Xultophy 100-3.6 100 unit-3.6 mg/mL (3 mL) insulin pen is medically necessary for treatment of this patients type 2 diabetes. 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 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested the WalkAide Functional Electrical Stimulator for treatment of her footdrop. Findings:  Two physician reviewers found that the footdrop is managed with either plastic molded ankle foot orthoses or double-metal upright ankle foot orthoses, depending on various clinical factors. In certain instances, patients with footdrop may have significantly improved gait mechanics with use of a functional electrical stimulator unit like the WalkAide when compared with standard ankle foot orthoses(Hausdorff and Ring). When this is found to be the case, a functional electrical stimulator unit is medically justified. Recently, this equipment has been increasingly used for both gait training and as an adaptive device to improve functional gait.  In the case under review, the patient's gait was significantly enhanced by the device when compared with the use of standard ankle foot orthoses.
Appeal type: Experimental/Investigational
Decision: Overturned

A 24-year-old female enrollee has requested Prometheus testing for evaluation of her hematochezia.  Findings:  Two physician reviewers found that in this patients case, the testing at issue was likely to have been of greater benefit than other methods of evaluation.  Differentiating ulcerative colitis from Crohns disease can be diagnostically challenging.  However, establishing a diagnosis is critical for treatment planning.  Serologic testing for inflammatory bowel disease has been shown to aid in differentiating ulcerative colitis from Crohns disease.  The current literature has demonstrated the utility of the testing at issue in this setting.  In sum, Prometheus testing provided on the said date was likely to have been more efficacious than other available alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for viscosupplementation injection (Orthovisc CPT code J7324) to both knees. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested viscosupplementation injection (Orthovisc CPT code J7324) to both knees are supported as medically necessary for treatment of this patients knee osteoarthritis. 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 orthopedic 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.