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 a vacuum erection system. The submitted documentation supports the medical necessity of the requested device. There are multiple options for the treatment of erectile dysfunction. Oral medication is the typical first-line therapy. Vacuum erection devices, intraurethral suppositories and intracavernous injections are second-line therapies for the treatment of patients who are refractory to oral medications. This patient has failed oral therapy. As such, the requested device is medically appropriate for the management of this patients erectile dysfunction. Therefore, the requested vacuum erection system is medically necessary for the treatment of this patient.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 urology 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 Otezla 30 mg BID. The Health Plan has denied this request indicating that the medication is not medically necessary for treatment of the enrollees plaque psoriasis. The submitted documentation supports the medical necessity of the requested medication. The enrollee is requesting coverage for Otezla for treatment of chronic plaque psoriasis. He has tried and failed therapy with topical steroids and methotrexate. The enrollee has a documented needle phobia. The enrollee has tried and failed a systemic agent. It is unreasonable to require the enrollee to undergo cognitive behavioral therapy or anti-anxiety medications to address the needle phobia prior to approving the current effective therapy, which is U.S. Food and Drug Administration approved for this enrollees condition. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla 30 mg BID is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees 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

The parent of an enrollee has requested authorization and coverage for Humatrope 24 mg cartridge.The submitted documentation supports the medical necessity of the requested medication. This patients height was below standard deviations the mean for his age and sex. The medical evidence supports the use of growth hormone therapy for the diagnosis of idiopathic short stature when a patients height is greater than 2.25 standard deviations below the mean for their age and sex. This patient meets this criterion for growth hormone therapy. Although he has entered puberty, his growth velocity has deteriorated, and he is now below the third percentile. Puberty is the time when most growth velocity occurs, and the fact that this patient actually deteriorated during that time signifies abnormal growth. This patient has a normal body mass index and a normal work-up otherwise. Thus, there is no other obvious reason to explain the patients poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 endocrinology, 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 patients parent has requested reimbursement for orthoptic training sessions and prospective authorization and coverage for sixteen (16) future weekly sessions, including progress examinations administered after every eight (8) training sessions. The patient has been diagnosed with binocular dysfunction, convergence excess, convergence insufficiency, pursuit dysfunction, and saccade dysfunction. The patient was noted to have midline crossing problems and difficulty with concentration. The patient was noted to have scored below average in eye movement testing. The patients ability to visually track a moving target was noted to be inaccurate and inefficient. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with convergence insufficiency. In this case, the requested in-office treatment program does not correlate with studied protocols in the literature. The patient has multiple diagnoses, including binocular dysfunction, convergence excess, convergence insufficiency, pursuit dysfunction, and saccade dysfunction. The medical evidence does not support the requested services in this clinical setting. Therefore, orthoptic training sessions and sixteen (16) future weekly sessions, including progress examinations administered after every eight (8) training sessions were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not and 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 ophthalmology 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 65-year-old female enrollee has requested for cataract surgery for treatment of her cataracts. Findings:  The physician reviewer found that Snellen visual acuity is worse than 20/50 with best spectacle correction. If glare testing reveals a disability of 20/50 or worse under conditions of induced glare, coverage is typically approved. In the case of this patient, she does not meet the accepted criteria for cataract surgery based upon her visual acuity. Further, glare testing did not indicate a disability of 20/50 in either eye. Although the patients cataracts are causing some visual disability, her glare disability is not severe enough to justify cataract surgery as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. One study notes that moderate-to-severe atopic dermatitis is defined as involving over 10% of body surface area (BSA) and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Another study notes that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and cannot be used long term due to these toxicities. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has moderate-severe atopic dermatitis with 24% BSA involvement. They have tried and failed therapy with triamcinolone and clobetasol. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent is medically necessary for the treatment of this patientFinal 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 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

The patient is a 50-year-old female with a diagnosis of severe osteoporosis. She was seen by an endocrinologist who recommended Forteo for the patient. The patient was instructed how to inject herself by a pharmaceutical representative in the endocrinologists office on 10/27/04. The patient apparently suffered an unspecified complication after three months of treatment and was not to continue to take Forteo or the medication for her multiple sclerosis. The patient is now seeking a follow-up appointment with the endocrinologist. The Health Plan has denied this request and indicates the patient can be managed by her primary care provider (PCP) with communication between the PCP and endocrinologist.The Health Plans denial should be overturned. The patient likely needs treatment for her osteoporosis. The PCP has not provided the patient with an alternative treatment plan since the patients request for a referral to the endocrinologist. As such, there is no evidence the patients osteoporosis is receiving appropriate management. Furthermore, given the failure of Forteo further evaluation by the endocrinologist is necessary to develop a new treatment plan for the patient. Therefore, I have determined the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Kadian 30 mg. Findings:  The physician reviewer found that the records provided for review document that this patient has failed conservative treatments in an attempt to control her chronic abdominal pain secondary to pancreatitis. In particular, the patient has tried and failed several non-opioid medications, epidural steroid injections, celiac plexus nerve block and has also failed generic MS Contin. Presently, the patient is functional and has good analgesia with Kadian 30 mg twice per day. This is a reasonable dose and the provider has documented the necessary first-line attempts at pain control. 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for social skills group therapy. The patient currently receives one-to-one applied behavioral analysis (ABA) services and speech and language services weekly. According to medical researchers, ABA has the most evidence supporting its effectiveness for treatment for children on the autism spectrum, and the patient is currently accessing these services and making significant gains. Further, the ABA provider highlighted that social interaction skills were a relative strength, and the speech evaluation identified auditory comprehension, expressive communication, and pragmatic judgment were within average limits. Based on this information, the requested social skills services group therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 psychology and am a board certified behavioral analyst 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: The patient has requested authorization and coverage for traditional duodenal switch surgery. Findings:  The physician reviewer found that records provided for review document that this patient has a history of obesity status post Roux-en-Y gastric bypass surgery in 2015. The patient states that she was able to lose weight from 340 pounds down to 220 pounds, but then she regained weight to 290 pounds. The patient has regained weight since the bariatric surgery, but she has not developed additional complications of morbid obesity. There is no report of additional metabolic complications, such as diabetes mellitus, as a post bariatric surgery complication to support an indication for duodenal switch surgery (OBrien, et al.). Therefore, the requested traditional duodenal switch surgery is not medically necessary for treatment of this patient.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 general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for an esophagogastroduodenoscopy (EGD). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy may be warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. Kim and colleagues note that gastric cancer screening with endoscopy should be considered in individuals from regions associated with a high risk of gastric cancer, including Asia, or who have a family history of gastric cancer.  In this case, the patient is of Asian origin with a family history of gastric cancer and has been treated with omeprazole with sucralfate. In this clinical setting, the requested service is medically indicated to evaluate the patients gastrointestinal symptoms. Therefore, an EGD is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fioricet. Findings: A study noted that there is a lack of data to support treatment with butalbital-containing agents in the treatment of patients with migraine. Similarly, another study found inadequate evidence for butalbital and butalbital combinations in the treatment of migraine in adult patients. Within the medical records available for review, there is documentation that this patient is undergoing treatment for chronic neck pain with a history of cervical spinal surgery. They also have a history of other chronic postprocedural pain, chronic pain syndrome, and dorsalgia. The provider indicated that Fioricet was recommended for the patients diagnosis of chronic pain. The patient has reportedly been treated with several medications for migraines without substantial improvement. However, there is a lack of support for a diagnosis of migraine in the records provided for review. Overall, the records do not support an indication for treatment with Fioricet. Therefore, the requested Fioricet 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 physical medicine and rehabilitation with subspecialty certification in pain management 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

The parent of a five-year-old male enrollee has requested for Applied Behavorial Analysis (ABA) therapy for treatment of the enrollees autism.   Findings:  Three physician reviewers found that ABA is an extensive one on one behavioral altering program that requires a skilled therapist working with the child 20-40 hour per week. Significant controlled studies have documented ABAs long-term effects on improving language, learning skills and socialization in autistic children. ABA is considered the gold standard of treatment of autistic children. No other therapy is likely to be more efficacious for this patient than ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for air and associated ground ambulance transportation services. Status migrainosus is a headache that persists despite treatment for more than 72 hours. Treatment of status migrainosus and intractable migraine focuses on adequate fluid hydration and combination intravenous therapy with non-opioid medications from multiple drug classes. Stroke, myocardial infarction, trauma injury, and intractable seizures are considered life-threatening conditions that require rapid medical intervention. In this case, the patient was diagnosed with status migrainosus, which is not a life-threatening condition that would require air ambulance transfer with ground transport at each end. The medical evidence does not support the services at issue in this clinical setting. Therefore, air and associated ground ambulance transportation services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 a cooling device (cooling pad with pump) for treatment of her medical condition. Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the device at issue in this patients case.  Kraeutler and colleagues compared the effectiveness of compressive cryotherapy versus ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression.  The authors noted that there did not appear to be a significant benefit to use of compressive cryotherapy units over standard ice wraps.  There is no indication that the patient would have greater benefit from a compressive cryotherapy unit versus traditional ice packs and bandaging.  All told, the superior effectiveness of a cooling device (cooling pad with pump) has not been established.  Final Result: Two reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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 parent of a 17-year-old female enrollee has requested neuro-rehabilitative services for the treatment of the enrollees traumatic brain injury (TBI). Findings:  The physician reviewer found that the patient is independent with gait transfers, dressing, hygiene and basic self care. The patient has received extensive physical, occupational, and speech therapy and numerous other therapies and counseling. The information provided demonstrates further therapy at such levels is not medically necessary. Furthermore, the information submitted demonstrates the patient can receive appropriate care through a less intensive program.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested for Genotropin recombinant growth hormone therapy for treatment of the enrollees lack of normal physiological growth secondary to isolated growth hormone deficiency. Findings:  The physician reviewer found that according to the growth prediction tables from the Greulich and Pyle Hand Atlas, this patient should achieve an adult height at or exceeding his mid-parental height without growth hormone therapy. As such, the patient does not meet generally accepted clinical indications for Genotropin recombinant growth hormone therapy.