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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall immediate release (IR) 20 mg twice a day, Adderall IR 20 mg three times a day, or in the alternative, Adderall extended release (XR) 30 mg every morning. As noted in the medical literature, attention-deficit/hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders among adults. For most patients with ADHD, first-line therapy includes medication management with amphetamines. While substance abuse or concurrent use of cannabis can create challenges in the setting of treatment of patients with ADHD with amphetamines, this alone is not a contraindication. This patient presents with multiple medical conditions including traumatic brain injury (TBI), seizures, and ADHD. The continuation of the patients medication regimen with Adderall is supported as consistent with current recommendations. Adderall XR dosed once per day will help enable the patient to be compliant with his regimen. Given these findings, the requested Adderall XR 30 mg every morning 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient is requesting Otezla, an oral phosphodiesterase inhibitor used for the treatment of psoriasis. She was treated with methotrexate for several years. It was recommended that she switch therapies given the risks of long-term methotrexate therapy. However, in this case there is no medical documentation of failure or intolerance to Enbrel or Humira. There is no documentation of contraindications to these therapies outside of age and risk of infection. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition. 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 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 35-year-old male enrollee has requested for Cialis 5mg daily (30 tablets) for treatment of his erectile dysfunction. Findings:  The physician reviewer found that There is a lack of support in the medical literature demonstrating the medical necessity of a daily dosage of Cialis. The effectiveness of Cialis, Levitra and Viagra are very similar, as seen in the above references. Results vary from one study to another, but a few studies have shown better results with Cialis. Daily low-dose Cialis (as opposed to the dosing recommended by the Health Plan) has not been shown to be medically necessary. This medication enhances a receptor by being a PDE-5 inhibitor. Although taking a daily dosage does allow the patient to take a lower dose and have the receptor inhibitor present on a daily basis, the use of daily low-dose Cialis has not been documented in the peer-reviewed literature to be more effective than the dosing of Cialis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested  readmission to a residential treatment center for treatment of the enrollees polysubstance dependence, oppositional defiant disorder, and depression, not otherwise specified.     Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with mood symptoms, chemical dependency and criminal behavior is a challenging endeavor.  As noted by the American Academy of Child and Adolescent Psychiatry, residential treatment is indicated for patients who do not meet criteria for hospitalization but whose lives have focused on substance use and who lack sufficient motivation or social supports to remain abstinent in an ambulatory setting.Per the submitted documentation, this patient has a burgeoning mood disorder.  She lacks motivation to stop using substances, and her social interactions focus largely on substance use.  Based upon the medical records, this patient lacks the psychological maturity to succeed in a less restrictive environment.  Due to this patients substance use, continued affective dysregulation and impulsivity, coupled with persistent negative schemas and psychosocial stressors, treatment at a lower level of care is likely to be unsuccessful.  All told, the requested readmission to a residential treatment center is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for treatment by an eye specialist. This patients records support the requested treatment by an eye specialist. The documentation indicates that the patient is a diabetic. The American Academy of Ophthalmology supports an annual dilated eye examination by an eye specialist to rule out diabetic retinopathy for patients with diabetes. In addition, this patient was a prior glaucoma suspect, which requires follow-up one to two times a year. The physician reviewer found that based on these findings, treatment by an eye specialist is medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the acupuncture services. For patients with low back pain, providers should consider the use of medications with proven benefits in conjunction with back care information and self-care. Providers should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options include acetaminophen or nonsteroidal anti-inflammatory drugs. For patients who do not improve with self-care options, providers should consider the addition of non-pharmacologic therapy with proven benefits. In this patients records, there is insufficient documentation of a patient work-up and tried and failed treatments to justify the need of acupuncture. The provider has not documented any physical/orthopedic examination of the low back, pain scales, functional deficits or failed conventional treatments. Therefore, the acupuncture services and future acupuncture services were not and are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested partial hospitalization level of care for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient was noted to have bradycardia and orthostasis. However, the degree of orthostasis is not known, and it is not established that the bradycardia was not related to exercising rather than her eating disorder. There is no indication of physiological compromise as evidenced by abnormal laboratory results and no indication of any history of risk to self or others. Per current guidelines, partial hospitalization level of care is indicated for patients who are less than 80 percent of their ideal body weight or are otherwise at risk for hospitalization due to physical complications or psychiatric comorbidity. This patient was above her ideal body weight. There is insufficient evidence of physiological compromise or serious psychiatric comorbidity to indicate that she was at risk for inpatient treatment or that she could not have been safely and effectively managed in a less intensive treatment setting.  In this patients case, she could have safely and effectively been treated at the intensive outpatient level of care during the period at issue.  All told, partial hospitalization level of care provided was not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cell-free fetal DNA-based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes for evaluation of the enrollees pregnancy.  Findings:  The physician reviewers found that Fetal aneuploidy screening is supported for all pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine. Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes. This patients age places her at increased risk for all fetal chromosomal abnormalities. Currently, the screening test of choice is cell-free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. There is sufficient support for the services at issue in this patients case. This technique has been highly validated and shown to have a high detection rate.  Therefore, cell-free fetal DNA-based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes provided was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: 2/3 of 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 reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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 authorization and coverage for fentanyl 50 mcg/hour patches by transdermal route (15 patches for 30-day supply) for treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that he documentation does not provide objective treatment goals for pain and no function were noted for the requested medication. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. In this patients case, tolerance has taken place since the start of the narcotics. The patients pain scores have remained the same despite increases in the amount of opioid he is taking. Ketamine infusions have been done and the 100% relief noted for three to four weeks were not corroborated with a decrease in any opioid usage. The provider has established no clear objective goals with this high of a dose of opioid. Moreover, the increases appear to have been done only on the basis of pain levels. There was no mention of behavior therapy in the documentation despite much research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for adult detoxification treatment. The submitted documentation supports the medical necessity of the services at issue. The records noted a history of suicidal ideation, and the patient had been abusing alcohol for over 30 years. A typical cut-off CIWA score that would qualify the patient for receiving treatment on an ambulatory basis is 15. Given that the patient had a score over 15 and a history of hypertension, inpatient care was medically necessary. The patient also reported a history of cardiac surgery. This is another medical complication that would indicate the need for inpatient care. All told, adult detoxification treatment was 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: Experimental/Investigational
Decision: Overturned

A 43-year-old male has requested rituximab for treatment of Wegeners granulomatosis.  Findings:  Two physician reviewers found that review of the medical literature reveals many reports of uncontrolled use of rituximab with benefit for WG in patients who have failed cyclophosphamide. The use of rituximab for the treatment of WG is now standard practice in rheumatology given the life-threatening nature of this illness.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Repatha Sureclick Injector 140 mg/mL for treatment of the enrollee who has a history hyperlipidemia.  Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided, the patient has a history of hyperlipidemia and he is noted as intolerant of statins and Zetia. However, there is no other documented coronary risk and he has a recent low coronary calcium score of only 9.  Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in patients with heterozygous familial hypercholesterolemia and in patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol. According to the submitted records, this patient does not fit either of these categories. The diagnosis of heterozygous familial hyperlipidemia requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease (younger than 50 years in second degree relative or younger than 55-60 years in first degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. The records do not support this patient has either heterozygous familial hyperlipidemia or clinical cardiovascular disease. There is a lack of literature supporting the use of PCSK9 inhibitors in patient populations such as this patient. For these reasons, Repatha Sureclick Injector 140 mg/mL is not medically necessary for treatment of the patients medical condition.  In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  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 internal medicine with sub-specialty certification in cardiovascular 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for the evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewer found that a fine needle aspiration (FNA) biopsy was suggestive of a follicular lesion of undetermined significance. A specimen was subsequently sent for Afirma gene classifier analysis. While a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. This test is very sensitive and has a high negative predictive value. A negative Afirma result is suggestive of a benign nodule and can therefore preclude surgical procedures. Final Result: The reviewer determined that the testing 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: 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: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested reimbursement for AlloMap Molecular Expression testing provided on two separate dates for evaluation of the enrollee, who is status post heart transplant.  Findings:  Three physician reviewers found that the patient underwent heart transplantation.  She has a history of hypertension.  Per the medical records, the patient is clinically stable following cardiac transplantation.  She has requested reimbursement for AlloMap Molecular Expression testing provided on two separate dates.  AlloMap Molecular Expression testing assesses the gene expression of circulating white blood cells.  It is intended to aid in the identification of rejection in stable heart transplant patients.  In order to monitor the heart muscle for cellular rejection, right ventricular biopsies are typically obtained at decreasing frequency of intervals after transplantation. These biopsies involve a risk of complications, including vascular complications, radiation, damage to the heart, cardiac tamponade, and arrhythmias.  Per the International Society of Heart and Lung Transplantation (ISHLT) guidelines for patients post transplantation, AlloMap testing can be used to rule out the presence of acute cellular rejection in appropriate low-risk patients between 6 months and 5 years after heart transplantation.  There is adequate medical literature supporting the testing at issue.  Thus, AlloMap Molecular Expression testing provided was likely to have been superior over other available alternatives for evaluating this patient.