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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Ajovy injections. As noted in the medical literature and by the American Headache Society (AHS), Ajovy injections are indicated for patients who have demonstrated failure of at least two medications such as topiramate, divalproex sodium, a beta blocker, a tricyclic antidepressant, or a serotonin norepinephrine reuptake inhibitor. Goadsby and colleagues reported that their study demonstrated the long-term safety, tolerability, and efficacy of Ajovy in the management of patients with migraine. However, the records provided for review do not adequately document failure of two or more medications from this list of preventative treatments for migraines. Thus, the patient does not meet the criteria for treatment with a calcitonin gene related peptide (CGRP) monoclonal antibody. Based on the current medical literature and AHS guidelines, the requested Ajovy injections are 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Findings:  Two physician reviewers found that Parkinsons disease is a chronic and progressive movement disorder that involves the malfunction of vital cells in the brain, specifically in an area known as the substantia nigra. These cells produce a chemical known as dopamine. As the disease progresses, the amount of dopamine produced decreases. In this case, the issue is whether the patient has Parkinsons disease. The patient has tremors, which are non-specific. In addition, he has gait abnormalities as well as depression and dizziness. At the time of the DaT-SPECT scan, the records indicate the patient did not have a diagnosis of Parkinsons disease. As noted in the current peer-reviewed medical literature, DaT-SPECT scans are most valuable when there are no absolute signs or symptoms suggestive for Parkinsons disease other than a tremor. Although a positive DaT-SPECT scan does not differentiate between the various parkinsonian syndromes, it is valuable in excluding a simple essential tremor which is more common given this patients age. Final Result: Two reviewers determined that the diagnostic procedure 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 physician reviewers are board certified in diagnostic radiology 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

The patient is a 49-year-old female with a body mass index (BMI) of 40.6 who is seeking authorization for weight loss surgery. The information provided indicates she has not undergone a psychological examination. The Health Plan has denied authorization for the requested surgery because there is no evidence the patient has undergone a supervised weight loss program.With a BMI of 40.6 the patient meets nationally accepted guidelines for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast exam.  Findings: Three physician reviewers found that Tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. The patient underwent an excisional biopsy and then had follow-up mammography. Considering the prior biopsy and the resultant scarring, a tomosynthesis exam was clinically indicated. In addition, 90 days later she underwent a follow-up mammogram with tomosynthesis. The repeat tomosynthesis was warranted to compare the previous bilateral studies. Therefore, the breast tomosynthesis performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedures 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 physician reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz 80 mg/mL auto-injector pen. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Taltz is a U.S. Food and Drug Administration (FDA) approved injectable biologic for the treatment of plaque psoriasis. Taltz works by a distinct mechanism of action by blocking IL-17 signaling.  Both Humira and Enbrel are FDA approved therapies for the treatment of plaque psoriasis which work by the same mechanism, namely blocking tumor necrosis factor (TNF) signaling. Head to head studies have shown that Taltz is superior to Enbrel in clearing plaque psoriasis. Given that the patient has already lost control of plaque psoriasis using a TNF inhibitor, it is not expected that the patient will achieve superior results with another TNF inhibitor. Therefore, the request for Taltz 80 mg/mL auto-injector pen is medically necessary for treatment of the patients chronic plaque psoriasis.  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 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

The representative of a 30-year-old male enrollee has requested coverage for diagnostic testing for treatment of the enrollees progressive neurological symptoms. Findings:  The physician reviewer found that there is no clear demonstrable role for the proposed diagnostic testing. The rationale for the requested cisternogram and CT myelogram is not clear from the information provided. Furthermore, no evidence has been provided which shows how information derived from any of the proposed tests would be clinically useful in this setting. Given the lack of compelling evidence that the proposed tests will have a significant impact on the patients treatment plan, the medical necessity of the requested diagnostic testing has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This applies whether the patient has cirrhosis or lack of fibrosis. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested Lyrica for the treatment of her polyneuropathy. Findings:  The physician reviewer found that the medical record indicates that the patient had previously used Neurontin 1800 mg and  Elavil 25-75 mg. These medications were unsuccessful in managing her neuropathic pain. Subsequently, Lyrica 75 mg twice a day was prescribed by her treating neurologist and the patient had significant improvement. Given the patients inadequate response to Elavil and Neurontin, Lyrica was the next reasonable choice in treating her neuropathic pain. Continued treatment with Lyrica is medically necessary as it has relieved the patients pain without untoward side effects.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male has requested rhinoplasty for treatment of his deviated septum.   Findings:  The physician reviewer found that nasal septoplasty is a surgical procedure that has been shown to improve the functional breathing in patients with confirmed evidence both on physical examination, failure to improve with topical or oral medications, and x-ray evidence of bony deformity. The article by Stewart and colleagues documents the clinical findings, response to medications, as well as surgical outcomes in patients with confirmed nasal septal deformities. The authors reported that patients undergoing that surgical intervention improve substantially and have a better outcome. Rhinoplasty is a procedure designed to improve the external appearance of the nose.  Alone, rhinoplasty usually is a cosmetic procedure. Septoplasty/rhinoplasty is a combined surgical reconstruction of the nasal septum and functional improvement of the external nasal dorsum to correct breathing difficulties unresponsive to medical manipulations including topical nasal sprays, antibiotics and allergy intervention. In this case, the patient meets the criteria for septoplasty/rhinoplasty because of anatomic and functional nasal airway blockage with internal nasal septal deviation to the left with obstruction, and external deviation of the nasal dorsum to the right. This procedure is supported and well documented in the article by Becker and colleagues. The patient does meet medical, anatomical and radiographic documentation that he has a fairly significant nasal septal deformity blocking the airflow of the left nasal cavity. This has been fairly longstanding condition and has not improved with appropriate medical management. All told, the requested surgery is designed to improve function. The patient does meet clinical and anatomical as well as radiologic criteria for consideration of functional nasal septal surgery. Under proper care, the surgical intervention can also create a normal appearance of the external nose to the extent possible. It is uncertain whether the surgery will provide more than a minimal improvement in the appearance of the patient in the absence of photographs. However, since the requested septoplasty/rhinoplasty is supported as reconstructive in nature, it is recommended that the patient follow-up with the surgeon to perform functional nasal reconstruction as requested.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing. Findings:  Three physician reviewers found that, in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment options for those plagued with psychiatric illness. However, despite its promise, genotype tests is not currently superior to the existing mainstream clinical application.  The medical literature does not recommend genetic testing for cases involving routine medication management. Moreover, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines. Further, the APA recently acknowledged the potential value of genetic testing but stopped well short of endorsement, noting the following, More research is needed before genetic testing can be recommended for routine clinical use. Additionally, a thorough search of the current literature failed to return well-designed or adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genotype testing and its relationship to specific pharmacologic interventions. This is likely due at least in part to the fact that many other factors are involved in drug metabolism besides a patients genetic makeup, such as smoking status, diet, concurrent treatment therapies, and other environmental and physiological factors. The current lack of such exploratory and confirmatory studies is another factor that renders genotype testing experimental/investigational for the evaluation and treatment of anxiety and mood disorders. Finally, it is unclear if this patient had exhausted standard treatments available to treat her condition. In sum, considering the relevant peer-reviewed literature and current practice standards, the disputed genotype test performed was not likely to have been more beneficial than any available standard therapy for the evaluation of this patient. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with contrast for evaluation of the enrollees dense breast tissue. Findings:  The physician reviewer found that the records in this case indicate that the mammogram including tomosynthesis and spot compression films continue to be concerning. Moreover, biopsy of the suspicious area is not possible since the area cannot be triangulated for accurate localization. The negative ultrasound is reassuring, but does not confirm that the area of mammographic concern has been examined since it is visible on only one plane. In this patient, further evaluation is indicated in light of the change in the mammographic findings, the dense breast tissue, and the positive family history of breast cancer. Magnetic resonance imaging (MRI) is the procedure of choice for problem solving in this type of patient. A negative MRI would be of great assurance that imaging surveillance is indicated while a positive study would allow the adequate triangulation of the suspicious area for tissue sampling. All told, the records provided for review demonstrate that the requested bilateral breast MRI with contrast is medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 parent of a seven-year-old female enrollee has requested weekly speech therapy for treatment of the enrollees childhood apraxia of speech and mixed expressive/receptive language delay. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of speech therapy. A mixed expressive/receptive language delay associated with Down syndrome has been documented and the patient has been assessed with apraxia. Speech therapy is generally considered medically necessary when performed for the purpose of improving functional skills. For patients such as this patient with mixed expressive/receptive language delay and apraxia associated with Down syndrome, speech therapy goals are focused on language-based skills; as such, speech therapy is not necessary from a medical standpoint. However, it should be noted that this patient also has a history of cleft palate and is status post surgical treatment, which may contribute to the apraxia. No standardized testing of articulation has been performed to correlate these issues. In the absence of identification of the specific factors that are affecting the patients expressive language/speech intelligibility via standardized testing of articulation, the medical necessity of speech therapy is not established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for human growth hormone (GH) therapy with Nutropin AQ for treatment of the enrollees small for gestational age (SGA), poor weight gain, and short stature. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved an indication for the use of GH therapy in patients with SGA. It is estimated that 9 out of 10 children born SGA experience rapid catch-up growth during the first 12 months of life, but 10-15% do not experience catch-up growth. The data in the medical literature indicate that GH treatment in short children born SGA is intended to achieve more normal height in early childhood, then maintain a normal height gain and reach adult height within the normal target genetic range. The records indicate that this patient was born early and at six years, his weight is consistent with a four-year-old, and a height age of 3.5 years. Given the bone age of seven years at a chronological age of five years eight months projects a very low adult predicted height of five feet two inches. This is well below the genetic target of six feet one inches. Of note, the bone age is typically delayed compared to chronological age in short prepubertal children born with SGA. The laboratory studies obtained so far in this patient indicate normal insulin like growth factor-1 (IGF-1) and normal insulin like growth factor binding protein-3 (IGFBP3). Provocative GH stimulating testing has not reportedly been done. GH deficiency appears extremely unlikely in this setting given these data. Given this patients presentation, treatment with human GH therapy with Nutropin AQ is supported as medically necessary. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuous positive airway pressure (CPAP) rental for treatment of her medical condition.  Findings: The physician reviewer found that the current medical evidence does not support the equipment at issue in this clinical setting.  If a patient does not have hypertension, heart disease or a cerebrovascular accident, the criteria for the medical necessity for CPAP is an overall study AHI of 15 or greater.  In this patients case, her Epworth Sleepiness Scale score was below 15.  There is a lack of support for the equipment at issue in this patients case.  Therefore, CPAP rental was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the equipment at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing.  The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.