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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Elidel cream for treatment of the enrollees eczema.  Findings:  The physician reviewer found that Protopic and Elidel are the first two non-steroidal drugs approved for the treatment of atopic dermatitis. Patients with atopic dermatitis have decreased quality of life, leading to distress, anxiety, and sleep disturbance. Both medications have shown significant positive effects in the treatment of atopic dermatitis without adverse effects seen with corticosteroid therapy. Elidel 1% applied twice daily for three to six weeks is effective at controlling the signs and symptoms of atopic dermatitis in patients with predominantly moderate disease, using atopic dermatitis severity scores as end points. In long-term studies of up to one year, Elidel 1% applied twice daily as needed for initial symptoms of atopic dermatitis, reduced atopic dermatitis flares, and thus the need for topical corticosteroids. Protopic has also been shown to be an effective treatment for moderate-to-severe atopic dermatitis in adults and children in multiple clinical trials up to two years in length. Protopic and Elidel are macrolactams with immunosuppressive characteristics. Both exert their immunosuppressive effects by inhibiting the activation of T-lymphocytes, thereby decreasing the release of the various proinflammatory cytokines. Thus, both medications work at the same disease pathway with equal efficacy. Given these findings, the requested Elidel cream is not supported as medically necessary in this patient who is already being treated with Protopic.  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 physician 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: Overturned

A 51-year-old female enrollee requested authorization and coverage of a colonoscopy screening for cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pifeltro. Sax and colleagues noted that, Initiation of antiretroviral therapy (ART) often leads to weight gain. While some of this weight gain may be an appropriate return-to-health effect, excessive increases in weight may lead to obesity. This patient reports that he experienced weight gain with Biktarvy. However, the records provided for review do not include documentation to support weight gain. The only weight charted for this patient was on 3/19/21 when he weighed 198 pounds with a body mass index (BMI) of 28.4 kg/m2. Moreover, Pifeltro has also been associated with weight gain. Absent documented weight gain with his current regimen, there is a lack of clinical rationale to support a change in therapy. All told, the requested Pifeltro is 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious 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: Upheld

A 48-year-old male enrollee has requested authorization and coverage for gastric bypass surgery. The patient has a body mass index (BMI) of 46. His comorbidities include hyperlipidemia, degenerative disc disease, bladder incontinence, diabetes mellitus, sleep apnea, and depression. He has requested authorization for gastric bypass surgery. The Health Plan states the patient needs to obtain psychological clearance and undergo nutritional counseling before weight loss surgery can be authorizedWith a BMI of 46 and comorbid conditions, the patient is likely to benefit from gastric bypass surgery. He does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, the patient has not yet obtained psychological clearance for weight loss surgery. Therefore, gastric bypass surgery is not medically indicated at this time. The patient should receive another psychological evaluation in six months to determine if he is an appropriate candidate for weight loss surgery. If he is considered an appropriate candidate at that time, then the requested surgery should be authorized.Based upon the information set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should undergo another psychological evaluation in six months.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet rich plasma (PRP) therapy. Findings:  The physician reviewer found that current evidence based medical guidelines support PRP intra-articular injections in the knee for significantly symptomatic osteoarthritis or refractory patella tendinosis. Guideline indications for significantly symptomatic osteoarthritis include the failure to respond to conservative nonpharmacological (i.e. exercise) and pharmacologic treatments after at least six months, and failure to adequately respond to aspiration and injection of intra-articular steroids. There should be evidence of mild to moderate osteoarthritis of the knee, and the patient should be over 50 years of age. For refractory patella tendinosis, criteria include failure to respond adequately to recommended conservative nonpharmacological and pharmacologic treatments after at least 12 months. Zhang and colleagues indicated that despite a lack of consensus regarding PRP indications and efficacy, there was widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. They concluded that further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis. Shahid and Kundra concluded that there was a growing body of evidence to support its use for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee. As such, the evidence for PRP therapy is of variable quality and concerns include the heterogeneous nature of the patients, variations in treatment techniques and inconsistencies in the findings of these studies. Additionally, there is a lack of hard evidence in regards to its effects in this clinical setting. The literature recommends that before widespread use can be recommended, high quality prospective randomized studies are required. Therefore, PRP therapy was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in orthopedic surgery 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

A 29-year-old female enrollee has requested gastric bypass surgery for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria for weight loss surgery set by the National Institutes of Health. Her BMI is greater than 40, and she will benefit from a weight loss surgical procedure. Weight loss surgery has been demonstrated to be superior to diet and exercise plan for treatment of morbid obesity. It is not likely that the patient will achieve adequate weight loss without surgery. Further, there is a lack of scientific data to support the requirement that the patient participate in a medically supervised weight loss program prior to weight loss surgery. The evidence does not demonstrate an improved outcome for patients who participate in pre-surgical medically supervised weight loss programs.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary. An enrollee has requested arthroscopic or open ankle surgery repair with bone graft and cartilage allograft for treatment of the enrollees right ankle injury. Findings: Two physician reviewers found that the patient complains of right ankle pain. The patient was snowboarding several months ago and sustained a suspected pronation injury to the right ankle, after missing a jump. The patient noted immediate pain and presented to the emergency department where he was instructed to limit weight bearing and use crutches for a possible hairline fracture. The pain initially resolved, but when he increased his activities, there was an acute increase in his symptoms. The patient was found to have an osteochondral lesion of the talar dome. The diagnosis is listed as osteochondral lesion (fracture) and missing cartilage and bone of the talus. The patient is requesting coverage for arthroscopic or open ankle surgery repair with bone graft and cartilage allograft. The Health Plan has denied the requested services as experimental or investigational for treatment of this patient. There is support in the medical literature for the requested services in this clinical setting. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus is known to be an effective method for management of focal chondral defects.  This method relies on the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect.  Studies have demonstrated that it is a rapid, safe, and effective treatment for cartilage defects.  In light of the foregoing, the arthroscopic or open ankle surgery repair with bone graft and cartilage allograft is likely to be more effective than other modes of therapy for the treatment of this patient.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgeon 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 a gastroenterologist consult. Camilleri notes that while traditionally the diagnosis of irritable bowel syndrome (IBS) has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating, several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions that may lead to IBS symptoms. The authors further note that such dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments. Lacy and colleagues report that IBS diagnosis may involve diagnostic testing. In this case, the patient has chronic gastrointestinal symptoms consistent with IBS, and has ongoing symptoms despite attempting recommended medical therapies for the treatment of IBS. Given that this patient has not responded to first-line treatments for IBS and as alternative possible diagnoses must be considered, the requested service is medically indicated. Therefore, a gastroenterologist consult is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastrointestinal tract capsule endoscopy for evaluation of a history of nausea, vomiting and abdominal pain. Findings:  The physician reviewer found that medical evidence fails to demonstrate the superior efficacy of the requested services in this patients case. Community standard indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes. Additionally, capsule endoscopy may be beneficial for evaluating the small bowel for tumors such as lymphoma, carcinomas or carcinoids. Per the records, this patient meets none of these indications. All told, gastrointestinal tract capsule endoscopy is not likely to be more effective than other modalities for evaluating this patient.   Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Aimovig. Findings: The U.S. Food and Drug Administration (FDA) has approved Aimovig for the treatment of patients with migraine. A study found that Aimovig reduced the number of monthly migraine days in patients with chronic migraine compared to patients treated with placebo. The authors concluded that Aimovig is a potential therapy for the treatment of patients with migraine. Another study found that, significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. The records provided for review document that this patient has failed treatment with multiple medications including topiramate, amitriptyline, and Imitrex. There are no contraindications to Aimovig evident in the patients medical history. All told, the requested Aimovig 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 with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 65-year-old-female who is status post cholecystectomy in 2005. According to the record provided for review, she saw her provider several times in early 2006 with a complaint of persistent abdominal pain. The patients provider ordered an abdominal CT to further investigate the source of the patients pain. The patient had the CT performed in April 2006 and has requested reimbursement for the cost of the diagnostic procedure. The Health Plan denied the request, citing a lack of medical necessity.This patient is status post cholecystectomy in 2005 and later developed abdominal pain.  The record indicates the patient saw her provider three times with this complaint, and after examination of the patient, the provider ordered an abdominal CT scan for further evaluation. As the etiology of the patients pain was unknown, abdominal CT was a reasonable approach and likely to provide a better view of the abdomen and more complete information regarding any pathological processes. Therefore, I have determined the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested  for bilateral temporomandibular joint reconstruction with custom right and left joints for treatment of the enrollees advanced degenerative joint disease with associated malocclusion. Findings:  The physician reviewer found that this disease process has resulted in loss of vertical mandibular height and a change in occlusal relationship.  The treatment of patients with severe anatomic and functional joint disorders is challenging.  Classically, in growing patients with disorders affecting the temporomandibular joint, reconstruction with autogenous tissue has been performed.  However, reconstruction with autogenous tissue can be unpredictable.  More recently, alloplastic reconstruction of the temporomandibular joint in growing patients has been proposed as an option in patients with severe joint pathology. Although alloplastic reconstruction of the temporomandibular joint shows promise, there are limited studies assessing the viability of the use of alloplastic temporomandibular joint reconstruction in this clinical setting.  All told, the requested bilateral temporomandibular joint reconstruction with custom right and left joints is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a six-year-old male with a history of speech delay and poor social interaction skills. The patient has a history of chronic diarrhea and failure to thrive as well as chronic otitis media requiring PE tubes. A request has been made for continued speech therapy. The Health Plan has denied the request indicating that continued speech therapy is not medically necessary.This patient has well documented speech and language delays affecting overall communication and social interactions. The diagnosis of control auditory processing disorder is somewhat controversial and the theory has not been scientifically tested. Despite this, there have been general studies and meta-analysis of childhood speech disorders that do demonstrate efficacy in the treatment of speech and language. The patients developmental pediatrician has documented improvement in the patients social skills, speech fluency and communication since the patient began speech therapy. Given the documented improvement and the likelihood that the patient will continue to benefit, from continued speech therapy is medically indicated.Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Speech therapy should continue as long as gains can be documented using standardized validation testing. Objective goals that demonstrate functional gain should be documented. The patient should be reevaluated at bi-monthly intervals by his developmental pediatrician to review standardized testing and document improvement.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Shingles vaccine treatment for history of shingles.  Findings:  The physician reviewer found that the request for Shingles vaccine is not medically necessary for treatment of the patients medical condition. In this case, the records do not demonstrate that the patient has recurrent zoster although she had pain at the site of a prior eruption two years later. Even if recurrent zoster is present, the Shingles vaccine has not been shown to reduce the recurrence rate. Final Result: The reviewer determined that the requested service 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 in infectious 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: Upheld

The parent of an eight-year-old male enrollee requested developmental, individual-difference, relationship-based model (DIR)/Floortime services for medical treatment of the enrollees autism spectrum disorder.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. The medical literature strongly supports the treatment of autism with ABA therapy in children. ABA therapy has been documented to significantly improve motor, verbal, and social interactive skills in autistic children. A review of the medical literature reveals a lack of independent studies on DIR/Floortime and clinical evidence to support the efficacy of DIR/Floortime interventions. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of DIR/Floortime interventions, it is not possible to conclude that DIR/Floortime is likely to be more beneficial than standard therapies available in this setting. Therefore, the requested services are not likely to be more beneficial for this patients medical condition than any available standard therapy.