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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for temazepam. The available documentation supports diagnoses of major depressive disorder (MDD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), sedative hypnotic use disorder, and insomnia. The patient has requested treatment with temazepam. However, each of the patients providers have recommended against ongoing treatment with temazepam. As recommended in the clinical guidelines and medical literature, the providers have weighed the risks of treatment with a sedative-hypnotic medication as outweighing the benefits to this patient. The patient has a history of escalating doses of their sleep medication on their own and has reportedly overused these medications to the point of potential overdose. Additionally increasing the patients risk is their regimen including opioids for pain management. Moreover, the patients records do not document that the patient has failed a course of cognitive behavior therapy (CBT) for insomnia or other first-line treatments that are not medication-based. Long-term use of temazepam is not clinically indicated for this patient. For these reasons, the requested temazepam 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultraviolet light therapy system panel for treatment of the enrollees aquagenic pruritus. Findings:  The physician reviewer found that there is sufficient support for the requested device in this clinical setting. This patient has a history of aquagenic pruritus. She has been treated in-office with phototherapy, with good resolution of symptoms. She has also tried and failed treatment with topical steroids and gabapentin. There is evidence in the medical literature of the utility of ultraviolet B phototherapy in the successful treatment of aquagenic pruritus.  Given that the patient has already had an in-office trial and found success with this treatment, a home unit is medically appropriate. Final Result: The reviewer determined that the requested device 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 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

A 50-year-old female enrollee has requested bariatric surgery (duodenal switch) for the treatment of her obesity. Findings:  The physician reviewer found that the requested bariatric surgery is medically necessary for treatment of this patient. The Health Plans denial is not medically appropriate. However, if the gastric outlet is blocked, a more appropriate procedure would be a Roux-en-Y gastric bypass.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested radiation/hyperthermia for the treatment of her invasive ductal carcinoma of the left breast. Findings:  Three physician reviewers found that hyperthermia given with radiation therapy as the primary treatment of breast cancer has no proven clinical benefit and at best is considered investigational. Systemic treatment, even simple hormonal therapy, would be an appropriate treatment in an effort to shrink the tumor maximally before applying any further local therapy, whether that will be conventional radiation therapy and/or surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with dyspareunia and vaginal atrophy. The patient reported persistent and worsening painful intercourse. The patient has been treated with vaginal estrogen two to three times per week, without improvement. The patient has requested authorization and coverage for Osphena. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Osphena is medically necessary for the treatment of the patients medical condition. The U.S. Food and Drug Administration (FDA), approved Osphena in 2013. The FDA noted, Osphena is an estrogen agonist/antagonist indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Tan and colleagues reported, Oral, transdermal, or vaginal estrogen preparations are the most effective treatment options for vulvovaginal atrophy-related sexual dysfunction. Selective estrogen receptor modulators such as lasofoxifene and ospemifene showed a positive impact on vaginal tissue in postmenopausal women. In this case, the patient has been diagnosed with dyspareunia and vaginal atrophy. She has tried vaginal estrogen, without improvement. The medical evidence supports the requested medication in this clinical setting. Therefore, Osphena 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 obstetrics and gynecology 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 in the peer-reviewed medical literature, Skaane and colleagues noted that to compare double readings when interpreting full field digital mammography and breast tomosynthesis during mammographic screening significantly improves the cancer detection rate in mammography screening. Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate in well selected patients. Accordingly, breast tomosynthesis was likely to have been more beneficial for evaluation of this patients medical condition.  Final Result:  Three reviewers determined that the service at issue was 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for insulin pump supplies including syringe (HCPCS A4232), disposable sensor (HCPCS A9276), and insulin infusion set (HCPCS A4230). This patients records document a diagnosis of type 1 diabetes complicated by autonomic dysfunction, depression, and asthma. The provider reports that the patient is on an insulin pump. In addition to improving glycemic control, insulin pump therapy can significantly improve the quality of life of diabetic patients (Ghazanfar, et al.). To maintain adequate glycemic control, this patient would benefit from closely tracking her blood glucose levels. To facilitate self-monitoring of blood glucose levels, a glucometer has been shown promising results (Al Hayek, et al.). It is important for this patient be able to use test strips which are compatible with her insulin pump. For these reasons, the requested insulin pump supplies including syringe (HCPCS A4232), disposable sensor (HCPCS A9276), and insulin infusion set (HCPCS A4230) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Upheld

A 61-year-old male has requested coverage for the cooling/heating device with pneumatic compression utilized during the time frame at issue for treatment of his status post left knee replacement.  Findings:  Three physician reviewers found that during post-operative evaluations, the patient was noted to be doing well, with no indication of a knee effusion. His range of motion was noted to be from 0 to 110 degrees. Physical therapy and anti-embolism (TEDS) stockings were recommended. It was also noted that the patient was going to physical therapy and 0 to 120 degrees of range of motion in his left knee.  There are limited published trials of cooling/heating devices with pneumatic compression for treatment of patients following knee replacement procedures. Cold compressive dressings were noted to be of no additional benefit in increasing range of motion, reducing swelling or reducing narcotic usage following total knee arthroplasty (Healy, et al.). There were no additional benefits of pneumatic compression devices when compared with standard treatment with ice following knee surgery (Dervin, et al.). There is no high grade published literature supporting the clinical efficacy of this device in this patients clinical condition. Moreover, given that the patient had no effusion following surgery this device would not have been expected to significantly improve the patients health or functional outcome over cooling provided by standard ice packs.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a prenatal ultrasound for evaluation of her vaginal bleeding during pregnancy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested prenatal ultrasound. While ultrasound evaluation in pregnancy is valuable, more than one ultrasound in the second and third trimester should be based on maternal or fetal complications. The practice guideline for the performance of obstetric ultrasound examinations recommends an obstetric sonogram in the second or third trimester that includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible. The medical literature further states The optimal timing for a single ultrasound examination in the absence of specific indications for a first-trimester examination is at 18-20 weeks of gestation. This patient had an ultrasound scan due to the patients recurrent vaginal bleeding, and another ultrasound was performed during an emergency department. This scan evaluated fetal growth, amniotic fluid volume and the placenta, but it did not re-evaluate fetal anatomy. As this patient has no risk factors for fetal anatomic abnormalities, another ultrasound for the purpose of fetal anatomic evaluation is not medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation 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 maternal fetal 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: Overturned

The patient is a 55-year-old woman with bronchial asthma and upper respiratory tract allergies. She had been treated with allergy immunotherapy and antiallergic /antiasthmatic therapy.  It is stated that the patient occasionally required pulse steroids and was using sodium cromolyn and beta agonists. She did not want to use inhaled steroids as she was diagnosed with osteoporosis. Subsequently, the patient was experiencing mild anaphylaxis on several occasions and required short courses of pulse steroids, and did not respond to the chronic use of inhaled sodium cromolyn. The treating physician requested a trial of Xolair to determine if this would help moderate the patients asthma in the absence of inhaled steroid and reduce her dependence on the daily use of Foradil and other rescue medications. Recent spirometry and IgE levels were indicative of asthma and atopic allergy. At issue in this case is whether Xolair is medically necessary for treatment of the patients medical condition.The Health Plans drug criteria indicates the patient meets all the criteria for provision of Xolair with the exception of documented use and failure to respond to maximum inhaled steroid dose in combination with long acting beta agonist and leukotriene for three months before requesting omalizumab.  The patient is not taking inhaled steroids due to a diagnosis of osteoporosis.  The Supplement to the Journal of Respiratory Diseases published October 2005 states The potential adverse effects of systemic corticosteroid exposure have been well established and include osteoporosis it was very clear that there was a puff-for-puff relationship between the amount of inhaled corticosteroids and the loss of bone density measured at the trochanter it is important to extrapolate this loss of bone density over the life of a woman The incremental rate of bone loss imparted by continuous use of inhaled corticosteroids would confer a 2-fold increased risk of hip fracture in that woman. Therefore, as the patient qualifies for treatment with Xolair in all other categories and is avoiding inhaled steroids because of osteoporosis, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

A 32-year-old female enrollee has requested an emergency room visit for the treatment of her ear pain. Findings:  The physician reviewer found that the symptoms of ear pain, redness, swelling of the ear and face, fever and chills could be indicative of several potentially life-threatening emergencies, including perichondritis, malignant otitis, mastoiditis, and facial cellulitis. It is critical to evaluate patients who might have such infections as soon as possible, as a delay in diagnosis and treatment can lead to an ominous outcome. It is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xifaxan tablet 550 mg. The American Gastroenterological Association (AGA) reports that small intestinal bacterial overgrowth (SIBO) is commonly diagnosed among individuals presenting with a variety of gastrointestinal symptoms. The AGA further reports that management includes the administration of antibiotics, but notes that there is a limited database to guide the clinician in developing antibiotic strategies for SIBO, and that therapy remains, for the most part, empiric. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan for the treatment of irritable bowel syndrome with diarrhea predominance (IBS-D). Medical literatures note that rifaximin has also been found to resolve symptoms in patients with SIBO, concluding that rifaximin appears to be effective and safe for the treatment of SIBO. Medical literatures report that rifaximin alters methane production. While data on rifaximin for SIBO in children are more limited, in a review of literature, researchers state, Taken together, these results indicate that antibiotics are an effective means of treating SIBO in children and, although non-rifaximin antibiotics appear to produce greater resolution, the data is weaker for such medications and rifaximin has demonstrated safety in a greater number of participants and studies. In this case, while information on the choice of antibiotics for SIBO treatment is thin, given this patients age and the presence of methane on a lactulose breath test, the requested medication is indicated as the safest and most effective treatment option. Therefore, Xifaxan tablet 550 mg 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 pediatrics with sub-specialty certification in pediatric 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: Upheld

The patient has requested authorization and coverage for Plaquenil 200 mg two tablets once daily. Based on the records provided for review, this patient does not meet the current American College of Rheumatology (ACR) criteria for systemic lupus erythematosus (SLE). There is limited documentation to include positive anti-nuclear antibodies (ANA), photosensitivity, and arthralgias. However, there is a lack of evidence of neurological symptoms and hematologic issues, or malar or discoid rash. Plaquenil has been associated with potential side effects with long-term use such as retinopathy and peripheral neuropathy. Moreover, the records do not include documentation that the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD), which is required for all patients prior to receiving Plaquenil. All told, the requested Plaquenil 200 mg two tablets once daily 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 rheumatology 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 19-year-old female enrollee has requested residential treatment services for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient has a very serious eating disorder, and she has required inpatient hospital care. She was admitted to an in-network facility, but she did not respond favorably to treatment. The facility discharged the patient for noncompliance. The patient then sought treatment at an eating disorder facility that was out-of-network. The patients need for inpatient care was fully established when she was initially admitted to the in-plan facility. In-plan physicians and reviewers did not deny the patients need for such care. This facility discharged the patient for noncompliance. This patient continued to need residential care. She was discharged from the Health Plans facility and admitted to the out-of-network facility shortly after. The second admission is only ten days subsequent to the first admission. She was discharged because the facility was not able to effect compliance, not because she did not need such treatment. This patient required residential treatment services. Such care was medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested the wearable cardioverter defibrillator for treatment of his congestive heart failure.  Findings:  The physician reviewer found that based on the records provided, the patient presented with congestive heart failure due to a non-ischemic cardiomyopathy with left ventricular ejection fraction of 25% while off medical therapy. In this circumstance, there is potential for recovery of left ventricular function and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Non-sustained ventricular was reported, but there is no documentation of the patient being symptomatic and it appears to have improved after titration of b-blocker therapy. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction with ejection fraction of 35% or less is documented to persist in spite of appropriate treatment (Russo, et al). Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction 35% or less before ventricular function has recovered have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk, where criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups (Chung, et al). A prophylactic wearable external defibrillator would only be indicated if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. All told, the wearable cardioverter defibrillator provided from the time period specified was not medically necessary for treatment of this patients medical condition.