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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ NuSpin 20 pen cartridge for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is a lack of clinical documentation of short stature, poor growth velocity, or poor adult predicted height.  Based on the information provided, the patient did not undergo a full, conventional two-agent provocative growth hormone test, with serial measurements for three to four hours of growth hormone levels in response to each of two agents.  Rather, one growth hormone response to clonidine and one response to L-Dopa were obtained.  The fact that the patient did not exhibit a robust growth hormone response to this abbreviated form of provocative testing does not prove that he is growth hormone deficient. Growth hormone provocative testing, even when performed completely, has poor sensitivity and specificity for a diagnosis of growth hormone deficiency in the absence of auxological data consistent with a growth disorder.  All told, the requested Nutropin AQ NuSpin 20 pen cartridge is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy for treatment of his gender dysphoria.  Findings: The physician reviewer found that the documentation provided supports the requested services in this clinical setting. Based on the documentation provided, the patient has gender dysphoria and is transitioning to the male gender. This patient has female breasts that would not likely resolve with continued hormonal therapy. Chronological age is not as important as the level of pubertal development in this patients case. The patients breasts appear to be consistent with a female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  This patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral mastectomy is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. The patient has evidence of abnormal breasts for a male as he is documented to have female Tanner stage V breast development. As such, the patients breasts are considered a developmental abnormality in a male. The plan of the surgery is to create a more normal appearance for a male chest. The requested services would create a relatively normal appearing male chest and would offer more than a minimal improvement in the appearance. For these reasons, bilateral mastectomy is reconstructive in nature and not cosmetic. Final Result: The reviewer determined that the requested services are medically necessary and 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 plastic 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

A female enrollee requested the peroral endoscopic myotomy (POEM) procedureal for treatment of the enrollees esophageal achalasia.  Findings:  Two physician reviewers found that given that the vast preponderance of clinical results have been extremely favorable for the POEM procedure, it is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation services. The submitted documentation supports the medical necessity of the services at issue. Per the records, the patient made consistent progress while receiving transcranial magnetic stimulation treatment. It appears that the patient made a return to her baseline level or near baseline level at the end the disputed 10 treatments. The exact number of transcranial magnetic stimulation treatments needed for successful depression symptom resolution is not clearly defined in the evidence-based literature. Some patients need more than 30 treatments for successful resolution of their symptoms. The number of sessions often needs to be considered on a clinical basis instead of a numerical basis. In this patients case, she was tolerating treatment well. There is support for the services at issue in this clinical setting. Therefore, transcranial magnetic stimulation services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 dialectical behavior therapy (DBT) for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that, in this case, the patients complex illness burden, consisting of but not limited to ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, limited coping skills and self-defeating coping strategies, increases the risk for a poor clinical outcome in the absence of appropriate treatment. Dialectical behavior therapy (DBT) is medically necessary for this patient as the record provides ample evidence of functional impairment stemming from the symptoms of borderline personality disorder. Further, the therapy has been recommended by clinicians familiar with the case while DBT is a trusted evidence-based intervention that benefits those with character pathology. Moreover, DBT is reasonably expected to improve the patients condition and prevent a more serious episode of illness. Therefore, DBT is medically necessary for treatment of the patients behavioral health condition.Final Result: The reviewer determined that the requested therapy 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 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

: An enrollee has requested authorization and coverage for Mydayis 12.5 mg.The current medical evidence supports the requested medication in this clinical setting. Mydayis has been approved by the U.S. Food and Drug Administration for the treatment of ADHD. Mydayis prescribing information notes that the effects of Mydayis may last up to 16 hours. The novel beaded technology of Mydayis allows a more individualized sustained release of the medication. The requested medication, Mydayis 12.5 mg, is appropriate to treat the patients ADHD and has effects that may last up to 16 hours, which is the duration of effect that the patient has been looking for and has not yet been able to achieve with medications thus far. Under these circumstances, the requested medication, Mydayis 12.5 mg, is medically necessary to treat the patients medical condition.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 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: Upheld

The patient is a 63-year-old female treated with non-steroidal anti-inflammatory drugs (NSAIDs), but her knee condition has continued to worsen. The patient does not wish to pursue conservative treatment of her osteoarthritis and wishes to proceed with total knee replacement.  The Health Plan has denied coverage for this procedure on the basis it is not medically necessary for treatment of the patients condition.Standard of care for treatment of osteoarthritis of the knee calls for a trial of physical therapy and NSAIDs prior to total knee replacement.  There is not sufficient justification for total knee replacement at this time. The patient may respond well to non-operative measures. Based upon the information provided, there are conservative treatments available for this patient that should be considered prior to surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested for bariatric surgery revision for treatment of her medical condition status post bariatric surgery.  Findings:  The physician reviewer found that in the literature, revisional surgery is associated with two to four-times the incidence of anastomotic leak, two-times the incidence of wound infection and other major morbidity. Revisional surgery has also been associated with increased mortality, this is because the operations are often complicated by the presence of adhesions (particularly to the liver), patients may still be morbidly obese, and tissue perfusion may not be optimal. Each of these factors can inevitably affect anastomotic healing.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested Vicodin, four tablets daily for treatment of his chronic pain.  Findings:  The physician reviewer found that Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. It is in the patients best interest to remain off all opioids. Short-acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, the requested Vicodin is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A forty-four year-old male with a diagnosis of chronic fatigue syndrome is requesting authorization an out-of-network referral.  Reviewers Findings:    The reviewing physician found that because of the complexity of the patients case an outside referral is appropriate.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Prolia injections. In the treatment of osteoporosis, Camacho and colleagues note that approved agents with efficacy to reduce hip, nonvertebral, and spine fractures such as denosumab (brand name Prolia) are appropriate as initial therapy for most osteoporotic patients with high fracture risk. The authors note that indicators of high fracture risk include advanced age, frailty, glucocorticoids, very low T-scores, and increased fall risk. In this case, the patient has a diagnosis of osteoporosis, with a T-score of -2.9 in the lumbar spine. The records note that the patient is unable to tolerate oral medications such as Fosamax due to gastrointestinal side effects and reported that the patient had previously been treated with Prolia. In this clinical setting, the requested medication is medically indicated. Therefore, Prolia injections are medically necessary for the 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 internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing (molecular profiling). There is a paucity of prospective randomized controlled studies demonstrating improved outcomes utilizing results obtained from expanded genetic panel tests. The American Society of Clinical Oncology (ASCO) guidelines continue to encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests. However, based on the current peer-reviewed medical literature, genetic testing has not been correlated with improved outcomes in this clinical setting. All told, the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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

The patient is a male diagnosed with hypoglycemia. The patient reported several episodes of hypoglycemia. The patients provider noted that on review of the patients blood glucose readings and food log, his hypoglycemia was likely due to a previous gastric bypass procedure. The patient has requested coverage for a Freestyle Libre continuous glucose monitoring system. The Health Plan denied the request and reported the requested device is not medically necessary for the evaluation of this patient. At issue in this case is whether a Freestyle Libre continuous glucose monitoring system is medically necessary for the evaluation of this patients medical condition. Hypoglycemia is an increasingly common complication of bariatric surgery that may result in mild to severe adverse health consequences. A continuous glucose monitoring system (CGMS) is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The Freestyle Libre is a new CGMS with a demonstrated reduction in hypoglycemic events for patients with diabetes. Although the FreeStyle Libre is currently FDA approved for patients with diabetes, it is helpful for detecting hypoglycemia for patients at risk for developing life-threatening hypoglycemia as well. Medical evidence supports the requested device in this clinical setting. Therefore, a Freestyle Libre CGMS is medically necessary for the evaluation 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: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression and anxiety disorder.  Findings:  The physician reviewer found that the body of medical literature supporting the use of transcranial magnetic stimulation (TMS) in the treatment of refractory depression continues to demonstrate positivism for this intervention. Researchers such as Ueyama and colleagues have identified a possible mechanism for the antidepressant effect of TMS. Most compelling in support of its application, TMS has been approved by the Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of patients with depression. In this particular case, the patient is experiencing an acute, recurrent major depressive episode that is causing significant morbidity and functional impairment. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice in the United States. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and is supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested IVIG therapy for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that the submitted documentation does not document prior treatment trials, time course, rate of exacerbations, degree of progressive dysfunction, current status or disability.  She is said to have history of chronic infection for which immunomodulatory therapy would not be appropriate.  Standard multiple sclerosis platform medications have been shown to reduce attacks and progressive disability, and although they alter immune function, they are not contraindicated in general for individuals with a history of chronic infection. Preventive management of relapses is the cornerstone of relapsing-remitting multiple sclerosis (RRMS) treatment, and disease modulator therapies are considered platform treatment.  In this patients case, the submitted medical records do not document trial, intolerability, failure or contraindication to standard therapies. Thus, IVIG therapy has not been shown in this case to be more beneficial than standard therapies for this patient.