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

Nature of Statutory Criteria/Case Summary:  An enrollees parent has requested authorization and coverage for Dupixent.Findings: The medical evidence supports the requested medication in this clinical setting. This patient has a diagnosis of atopic dermatitis. Past medications tried and failed include triamcinolone, fluocinonide, Elidel, topical tacrolimus, Eucrisa, and antihistamines. Per the submitted documentation, the patients eczema was not controlled prior to Dupixent. After starting on Dupixent, his symptoms are 70-80% improved and only require the use of topical triamcinolone cream. A study performed a randomized, double-blind, placebo-controlled trials involving adults who had moderate-to-severe atopic dermatitis despite treatment with topical glucocorticoids and calcineurin inhibitors. The authors noted, Dupilumab was evaluated as monotherapy in two 4-week trials and in one 12-week trial and in combination with topical glucocorticoids in another 4-week studyIn the 4-week monotherapy studies, dupilumab resulted in rapid and dose-dependent improvements in clinical indexes, biomarker levels, and the transcriptome. The results of the 12-week study of dupilumab monotherapy reproduced and extended the 4-week findings. The authors concluded, Patients treated with dupilumab had marked and rapid improvement in all the evaluated measures of atopic dermatitis disease activity. This patient has severe uncontrolled atopic dermatitis despite treatments with topical steroids (triamcinolone), topical tacrolimus and antihistamines, and his symptoms have impacted his quality of life. There is sufficient support for the requested medication in this patients case. Therefore, Dupixent 200 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 allergy and immunology 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 mother of a 16-year-old female enrollee requested authorization and coverage of inpatient behavioral health services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees bulimia.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief lasting six months with prior Synvisc-One injections. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc-One injection in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested comprehensive rehabilitation services in a day program for treatment of his status post hemorrhagic stroke and ischemic stroke.  Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this patients case.  Per the clinical records, this patient is approximately 2 12 years post cerebrovascular accident, with partial improvements during inpatient and ongoing day treatment therapy.  He has significant neurological residuals which may respond to ongoing therapies.  The current medical literature indicates that recovery can continue for several years post acute brain injury.  As this patient continues to make functional gains, ongoing therapy is medically indicated.  All told, comprehensive rehabilitation services in a day treatment program at Centre for Neuro Skills from the date in question forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old female who is requesting authorization for pterygium surgery.  The condition is causing her pain, inflammation and irritation. The patient has been using therapeutic eye drops without improvement in her signs or symptoms.  The consulting specialist recommends surgical excision with a conjunctival autograft and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.The consulting surgeon has recommended excision of the patients pterygium together with a conjunctival autograft.  This is appropriate therapy in light of the fact that the patient has considerable discomfort and has been using therapeutic eye drops without noticeable improvement.  The symptoms experienced by the patient do not constitute a cosmetic complaint, but rather a medical condition, which can be corrected with the proposed surgery.  Therefore, I have determined the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested Norco and Soma for treatment of his lumbar spondylosis and chronic pain syndrome.  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 a patients 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. In addition, 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. It is in the patients best interest to wean off the Norco and Soma. For these reasons, the requested Norco and Soma are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.  Digital breast tomosynthesis with [three-dimensional] 3D images might overcome some of the limitations of conventional [two-dimensional] 2D mammography for detection of breast cancer. Ciatto and colleagues investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. The authors concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. As such, the digital breast tomosynthesis performed was likely to be more beneficial for breast cancer screening than standard modalities. 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested  for child/adolescent-focused cognitive behavioral therapy with exposure and response prevention (E-RP) for treatment of the enrollees obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the therapy was successful, resulting in a full recovery without the use of medications. This particular specialized treatment program was on target for the needs of the patient and eliminated her symptoms of OCD and improved her quality of life in a brief period of time. The therapy was medically indicated and resulted in a dramatic improvement in the condition of the patient. It is also reasonable for the therapist that conducted the cognitive behavioral therapy to see the patient periodically to make sure that she does not move from the new baseline that has been established without the use of medication. Follow-up with this provider at three-month intervals for one year is clinically appropriate for reinforcement and monitoring.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Tandem insulin pump. Findings:  The physician reviewer found that According to Edem and colleagues, insulin pump therapy is an effective method for achieving glycemic control that provides flexibility both in basal infusion rates and the timing and frequency of prandial and correctional bolus dosing. The U.S. Food and Drug Administration have approved at least seven insulin pumps, all of which have slightly different approaches in providing a solution for those with insulin-requiring diabetes. Pinsker and colleagues state that the Tandem insulin pump allows for updatable software, which enables access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump. Recent data from Pinsker and colleagues suggests that this process results in sustained reductions in hypoglycemia, thereby improving overall glycemic control. Therefore, Tandem insulin pump is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in endocrinology, diabetes, 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: Upheld

A male enrollee requested Cialis 20 mg, 10 pills per month for medical treatment his erectile dysfunction. Findings:  The physician reviewer found that sexual dysfunction is a common side effect of megestrol acetate and treatment for erectile dysfunction is indicated.  However, the requested dosage is not medically necessary and the alternative of Cialis 20 mg #6 per month is appropriate. The requested dosage over the allowed amount is not justified by the medical literature. Therefore, the medical necessity of the requested medication dosage has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested for Sonata for treatment of his insomnia. Findings:  The physician reviewer found that its recommended zolpidem tartrate or Lunesta. The patients objections are predominately due to a negative experience with long-acting zolpidem tartrate, and theoretically, due to the duration of action of Lunesta.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage for surgery for treatment of sleep apnea. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient received services for alcohol use disorder. The medical literature supports services at the least restrictive environment if available. The patient could have obtained treatment for her alcohol use disorder at a lower level of care. Groups and therapy addressing alcohol use disorder are available as outpatient treatment options and do not require an inpatient stay. Moreover, the patient did not have any signs or symptoms of an acute psychiatric episode rendering her dangerous or destructive to self or others or grave disability that would require an inpatient stay. The records do not indicate that this patient had exhibited signs or symptoms of alcohol withdrawal that would have required 24 hours of close monitoring. Additionally, clinical notes show that this patient was independently engaging in everyday activities, which supports the patients ability to function as an outpatient. The patient was not exhibiting agitated, psychotic or intentions for self-harm or harm to others. For these reasons, the residential treatment services were not medically necessary for the treatment of this patients medical condition. 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 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: The patient has requested authorization and coverage for a lung transplant. This patient has end-stage interstitial lung disease. He is being treated with 6 liters of supplemental oxygen and chronic steroids. The medical records document that the patients recent body mass index (BMI) was 35. However, the records also document that the patient has lost weight over the past year. The patient reports a current BMI of 34. Morbid obesity, as defined as a BMI over 35, is a contraindication to lung transplantation. Providers may consider proceeding with placing a patient on the transplant list when the patient has demonstrated weight loss with changes in diet and exercise changes. Given the advanced nature of this patients lung disease and his documented weight loss, the requested lung transplant is medically necessary.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 subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 25-year-old female with a history of persistent nausea and vomiting. Vomiting has occurred as much as 14 times a week. There is also evidence of dental erosion from the vomiting. The patient has tried Reglan, erythromycin, Protonix, Zantac and Pepcid. A gastric emptying study demonstrated delayed emptying at two and four hour intervals.  The Heath Plan denied the patients request for authorization of gastric electric stimulation therapy based on a determination that the therapy is not medically necessary.The gastric stimulation device was approved by the FDA in March 2002. It was studied in the Worldwide Anti-Vomiting Electrical Stimulation Study (WAVESS), which demonstrated a 50% improvement in symptoms and quality of life over a 12-month period. The therapy reduced the rate of hospitalizations by 30% in the first year after implantation of the device. The benefits of this form of therapy were also reported in the GEMS study group from 1997 to 1999 and several other studies as noted above.The manufacturers study inclusion criteria is outlined in the Summary of Safety and Probable Benefit of the Gastric Electrical Stimulator. The patient meets these criteria as she has had symptomatic gastroparesis for greater than one year, been refractory or intolerant to at least two anti-emetic and prokinetic drug classes, had vomiting at a frequency greater than seven times per week, and had delayed gastric emptying defined as greater than 60% retention at two hours and greater than 10% retention at four hours.  The patients symptoms have continued despite a wide range of conservative therapies and treatment with the gastric electric stimulator is medically appropriate at this juncture. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old woman with a variety of non-specific somatic complaints diagnosed as multiple sclerosis by her family physician. The submitted information includes no evidence of a definitive diagnosis of multiple sclerosis by a neurologist. The patient had a minimally abnormal MRI, which was not suggestive of multiple sclerosis, a normal CSF evaluation, a normal SSEP evaluation, and borderline abnormal Visual Evoked Response. Her recent neurologic exams by several neurologists are negative. The patient has requested authorization and coverage for another MRI of the brain as well as an evaluation by a neurologist. The Health Plan indicates the requested services are not medically necessary for evaluation of the patients condition.The Health Plans denial should be upheld. The patient does not meet clinical or paraclinical definition of multiple sclerosis. The submitted records indicate the patient has seen several neurologists who are of the opinion the patient does not have multiple sclerosis. Further neurologic opinion and repeat MRI at this time are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the automated whole breast ultrasonography for evaluation of the enrollees left breast carcinoma status post lumpectomy. Findings:  The physician reviewer found that the records provided for review document that this patient has declined to have conventional mammography to avoid excessive exposure to radiation since 2011 and has been evaluated with annual automated whole breast ultrasonography exams. The American College of Radiology (ACR) does not recommend automated whole breast ultrasonography as a screening tool for breast cancer detection. The use of this technique has proven to be of some benefit in patients with dense tissue for use as an adjunct to conventional mammography. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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

A 59-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon. The Health Plan  denied the request indicating that the requested referral is not medically necessary for the enrollees follow-up care.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.