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

A 38-year-old male enrollee requested authorization and coverage of tonisllectomy and uvulopalatopharyngoplasty for the treatment of severe sleep apnea.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Synvisc-One in right knee. The American Medical Society for Sports Medicine (AMSSM) supports hyaluronic acid injections in the knees for patients who have failed to respond to conservative treatment and to potentially delay total knee replacement in patients with severe osteoarthritis and pain that interferes with functional activity. This patient presents with complaints of severe right knee pain with functional limitations. The patients right knee clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis, described as bone-one-bone. The records document that the patient experienced tachycardia with a recent cortisone injection. She is reportedly not a candidate for surgery. Given this patients functional limitations, and failure of conservative treatment, as well as contraindication to cortisone injections, the use of hyaluronic acid injections is appropriate. Thus, the requested Synvisc-One injection for the right knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oncotype DX Prostate Cancer Assay.Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) recommends Oncotype DX Prostate Cancer Assay for men with low-risk or favorable intermediate-risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. This prognostic information includes likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Patients with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate Cancer Assay was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the patient has a history of bariatric surgery and peptic ulcer disease.  Per the visit note, she was having symptoms daily with abdominal pain, with no relieving factors. An endoscopy showed a large post-gastrojejunal ulcer measuring approximately 3 cm, which was also noted on a previous endoscopy. Per the pathology report, biopsies showed ulceration, and no Helicobacter pylori was found. Although she was not taking her proton pump inhibitors regularly at the time of the first endoscopy, she was taking omeprazole 40mg twice daily for several months prior to the second endoscopy, and the ulcer persisted. A visit note states that a change from omeprazole 40mg twice daily to Dexilant has improved the patients pain for the first time. The patient has requested authorization and coverage for Dexilant 60mg daily.  The Health Plan has denied the request as not medically necessary for treatment of the patients peptic ulcer disease based on clinical policy, as the patient has not tried two alternative step therapies, including pantoprazole (Protonix) and lansoprazole (Prevacid). At issue in this case is whether the requested medication Dexilant 60mg is medically necessary for treatment of this patients medical condition.Proton pump inhibitor (PPI) therapy is effective for the treatment of gastrojejunal ulcer disease. This patient has failed a high dose of omeprazole, with no ulcer healing after months of use, and then experienced better control of her symptoms with Dexilant. Comparison of multiple PPIs, including the one attempted (omeprazole) and others (pantoprazole, lansoprazole, rabeprazole, esomeprazole), has found no difference in control and healing of gastroesophageal reflux disease (GERD) between them, but has demonstrated superiority of Dexilant to esomeprazole. Dexilant, unlike all other PPIs, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. Dexilant is more effective to treat symptoms than alternatives such as esomeprazole. The dose used is appropriate. In this case, the ulcer did not heal, despite treatment for several months with high-dose omeprazole. PPI options besides Dexilant are likely to be similar to omeprazole. For these reasons, Dexilant 60mg is medically necessary for the treatment of this patients medical condition.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 internal medicine with a 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: The patient has requested authorization and coverage for Cialis. The current medical literature supports the use of Cialis for treatment of vasculogenic erectile dysfunction. This patients records document erectile dysfunction and comorbid cardiovascular atherosclerotic disease status post quadruple bypass and carotid endarterectomy. Given the evidence of systemic atherosclerotic disease in the patients medical history, Cialis is an appropriate choice of medical therapy to benefit his erectile dysfunction without placing the patient at increased cardiovascular risk. Therefore, the requested Cialis is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 laser hair removal for treatment of the enrollees gender dysphoria.Findings:  The physician reviewer found that facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical condition where terminal hair grows in female in areas that are normally found in males. This would include the face, and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, the records noted that hormone therapy has not been effective in improving this patients medical condition. Therefore, laser hair removal is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal make-up of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. Therefore, for all these reasons, laser hair removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature 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: Upheld

 A 53-year-old female enrollee requested anesthesia (monitored anesthesia care (MAC)) administered during a colonoscopy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for MAC.  A colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of MAC with propofol, as required per American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compound thyroid cream with a combination of T3 and T4. Thyroid hormone therapy as an initial full replacement or as partial replacement with gradual increments in the dose titrated upward using serum thyrotropin is the goal of treatment in patients with hypothyroidism. Providers make dose adjustments when there are large changes in body weight, with aging, and with pregnancy, with thyrotropin assessment four to six weeks after any dosage change. A substantial number of studies on patients with TSH levels between 2.5 and 4.5 have reported beneficial response in atherosclerosis risk factors such as atherogenic lipids, impaired endothelial function, and intima media thickness. Although the treatment of choice remains oral levothyroxine, absorption can be affected by many factors, malabsorption syndromes and medications. Two peer-reviewed articles from researchers found promising results of transdermal delivery of levothyroxine. Considering this patients oral malabsorption due to lye injury of the upper gastrointestinal system and failure of standard therapies, the requested T3/T4 compound is a reasonable thyroid delivery option. Moreover, the patient had documented therapeutic response to the requested compounded preparation. The patients flow sheet of TSH levels demonstrate that over time, she has absorbed the transdermal compound, and not the oral preparations. Therefore, the requested compound thyroid cream with a combination of T3 and T4 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 subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rimegepant (Nurtec ODT). According to the 2015 American Headache Society (AHS) assessment of the evidence for individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks (Marmura, et al.). Small molecule calcitonin gene-related peptide (CGRP) receptor antagonists are a newer drug class called gepants. The U.S. Food and Drug Administration (FDA) approved Nurtec ODT, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults based on the results of a randomized, double-blind, placebo-controlled trial by Croop and colleagues. The study reported that the percentage of patients achieving headache pain freedom and MBS freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. Pringsheim and colleagues recommend that, when an initial treatment (for an acute migraine) does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive and preventative medications. Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults. Given this support, the requested rimegepant (Nurtec ODT) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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

A 60-year-old female enrollee has requested for bariatric duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific literature demonstrates that the long-term outcome of the duodenal switch operation is much better than that of the other procedures. This is true when one compares the percentage of excess body weight loss and resolution of comorbid conditions, including diabetes, hypertension or lipid disorders. The duodenal switch operation represents the best surgical operation for the treatment of obesity and the associated comorbid conditions and is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee has requested Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) for treatment of his hepatitis C virus. Findings:  Three physician reviewers found that Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) is likely to be more effective for this patient than other available options. There is data in the medical literature that supports the combination of a protease inhibitor Olysio and polymerase inhibitor Sovaldi for the treatment of hepatitis C genotype 1 patients. This is reflected in the guidelines issued by the American Association for the Study of Liver Diseases (AASLD). This combination may be given with or without ribavirin. In sum, in this patients case with an advanced cirrhosis eradication of hepatitis C the requested medication is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested a positron emission tomography (PET) scan for an evaluation of her probable frontotemporal dementia. Findings:  Three physician reviewers found that the issue in this case concerns whether PET scanning is likely to be more beneficial for evaluation of the patients condition than any standard modalities. The specificity of PET scan abnormalities in the diagnosis of frontotemporal dementia has not been adequately established. Overlap of supposed abnormalities in the workup of dementia with PET scan is prominent. Furthermore, there are no therapeutic implications to the results of PET scans in this instance. Accordingly, a repeat PET scan is not likely to yield information that will be of consequence to the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested for out-of-Plan referral for laser hair removal for treatment of his skin affected by pilonidal cyst.  Findings:  The physician reviewer found that the patient has persistent problems with recurrence of the cyst, then further surgical management may be warranted, but the requested referral for laser hair removal has not been established to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has been diagnosed with autism. By the age of seven, he has only vocalizations without understandable speech. However, he can carry out fairly complex commands indicating some degree of learning potential. His pediatrician has prescribed speech therapy. The speech therapist elected not to attempt to fully assess the patient until she had developed some understanding of his speech dysfunction. This did not constitute a failure to perform adequate pre-treatment evaluation, as it was well-established that the patient is aphasic. The plan of action with goals was a well-established program for speech therapy as noted in the article by Goldstein. Myers and colleagues state that most children with autistic spectrum disorder can develop useful speech, and chronological age, lack of prerequisite skills, failure to benefit from previous language and IQ scores should not exclude a child from receiving speech and language services. This patient has a five-year history of profound speech delay, and he does not need an extensive evaluation each time a speech therapy program is initiated. Speech therapy was and is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year, six-month-old male enrollee has requested physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that this patient has Down syndrome with typical gross and fine motor delays associated with the disorder. Significant developmental intellectual delay is also anticipated.  In the medical literature, Connolly and colleagues performed a controlled study of therapeutic interventions in Down syndrome children. The group that had various form of therapy demonstrated a significant improvement in gross motor skills on the Bruininks Oseretsky Test of Motor Proficiency compared to the non-treated group. In addition, Mahoney and colleagues also reported substantial improvement in infants with Down syndrome following one year of PT services. Although the authors could not estimate the effect of maturation contributing to the overall improvement versus that attributable to PT, by comparison, the patients who received therapy experienced greater progress than patients who were untreated. As such, it is medically necessary that this patient receive the requested PT services. The recommendation is for one hour of individual PT weekly for six months. If reevaluation demonstrates improvement, the PT services should be continued for another six months.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, this patient meets the criteria for IOP services. The patient has been at some risk of harm (score 2) due to substance use and reports of prior self-harm without suicidal ideation. The patient has demonstrated moderate functional impairment (score 3). The records document that she has a difficult relationship with her parents, but has shown recent gains in the IOP setting. Documentation supports significant comorbidities (score 3) due to the presence of psychiatric and substance use concerns. The patients recovery environment is mildly stressful (score 2) due to academic pressures from her parents. Her recovery environment is supportive (score 2), as her parents have participated in the IOP program, but struggle to be emotionally attuned to the patients difficulties. The patient has significantly improved since she started IOP treatment (score 2), given her ability to manage recovery in the context of the IOP. The patients parents have been obstructive to treatment (score 3), as they have been struggling to schedule and participate in family therapy. This gives the patient a composite score of 17, which is consistent with high-intensity community-based services, such as IOP. Given these findings, the IOP services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in child and adolescent 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.