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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cresemba 186 mg capsule, twice daily. This patient is receiving induction therapy for acute myeloblastic leukemia which is associated with a high risk of neutropenic fever. Some institutions administer prophylaxis with fluoroquinolones and/or antifungals (e.g., fluconazole, itraconazole, posaconazole, voriconazole, or amphotericin) during the period of neutropenia. The combination of Cresemba with any of the azoles carries a category D warning, except for fluconazole and Cresemba, which carries a category C warning on drug interaction check. Of note, amphotericin does not carry a drug interaction and could be use instead of Cresemba. Cresemba is not U.S. Food and Drug Administration (FDA) approved for use as prophylaxis and is not supported by major drug compendia for this indication. The National Comprehensive Cancer Network guidelines do not recommend Cresemba as fungal prophylaxis in acute myeloblastic leukemia. Therefore, Cresemba 186 mg capsule, twice daily is not medically necessary 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 internal medicine with sub-specialty certification in medical oncology 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

A 58-year-old female enrollee has requested for allergen-specific IgG testing for evaluation of her constipation and fatigue. Findings:  Three physician reviewers found that the proposed indication for the allergen testing is fatigue and constipation. The symptoms are non-specific and cannot be attributed to an allergy. Food allergies as a basis for non-specific symptoms as described above have not been reliably established as causative agents. There is a lack of human trials that establish food allergy as causative of fatigue and constipation. The investigation proposed is experimental and has no consistent support in the medical literature. Because the symptom of fatigue is non-specific, there is no specific treatment for it. The patient has no other symptoms of food allergy. Treatment of constipation does not require treatment for food allergy. The experimental investigation will not produce findings that will produce, better, more specific therapy than is available with standard evaluation of the complaints.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the right and left knee. The submitted documentation demonstrates the medical necessity of the requested services. The current literature supports the use of viscosupplementation for osteoarthritis of the knees. The current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. In this patients case, prior viscosupplementation was beneficial. Therefore, the requested Orthovisc injections to the right and left knee 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested bariatric surgery for treatment of his obesity. Findings:  The physician reviewer found that this patient has a BMI of 38.3 and hypertension, a significant co-morbidity. In addition, he has failed multiple weight loss attempts. Thus, it appears the patient has clinically severe obesity along with a significant co-morbidity and meets National Institutes of Health criteria for weight loss surgery. Therefore, the requested procedure is medically necessary for treatment of the patients medical condition. As part of the patients pre-surgical work-up, he should undergo dietary and behavioral evaluations as it does not appear these evaluations have been performed.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections of the left knee every six months. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has evidence of grade IV changes in the lateral tibial plateau noted at the time of arthroscopy in 2018. He has tried and failed various conservative therapies including NSAIDs, activity modification, and icing. The patient also underwent arthroscopic debridement without relief. He then underwent viscosupplementation, which gave him months of relief. In addition, the patients remaining treatment options are quite limited. The patient has tried and failed other conservative treatments as well as arthroscopy. The alternative is another arthroscopy with temporary relief or a unicompartmental knee arthroplasty at a young age. As such, requested Monovisc injections of the left knee every six months are medically necessary for treatment of this patients osteoarthritis of the knee.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 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

The parent of a nine-year-old female enrollee has requested the brand name drug, Focalin XR. for treatment of the enrollees attention-deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Generic products by definition should be considered interchangeable with the innovator brand product. However, the U.S. Food and Drug Administration (FDA) allowed variability in generic medication concentrations is +/- 20 percent (Carron and Correll).  Multiple studies over the last ten years have recorded this allowed variability. Carron and Correll performed a literature review of clinical studies comparing branded with generic psychotropic drug formulations. The authors reported that generic-generic switches may vary by more than +/- 20 percent from each other in individual patients since the pharmacokinetic properties of each generic may differ from the innovator drug in opposing directions. In this case, the patient has a diagnosis of ADHD and was responding well to a moderate dose of dexmethylphenidate in the form of brand name Focalin when a generic formulation became available. The patient tried the generic formulation, but the patients parent recognized significant behavioral and physical alterations after one month with the substitution. After a trial period of one month the generic methylphenidate was replaced with brand name Focalin with a resolution of the flared up symptoms. As such, the generic version has failed as reported by the patients parent and the continuation of brand name Focalin XR is medically necessary for this patient. In addition, increasing dosage of the generic medication would run the risk of side effects and take the patient beyond the recommended maximum dose. Therefore, the request for brand name drug, Focalin XR is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for custom orthotic inserts.Orthotics have long been utilized to help correct abnormal biomechanics of the foot, alleviating stress and strain from certain muscles, tendons, and ligaments. The medical records document that this patient has painful posterior tibial tendon dysfunction. The patient is noted to have failed conservative treatments, including pain medication, casting, and activity modification. The patient is noted to have calcaneal valgus upon stance and ambulation with foot images provided in the chart notes that demonstrate significant loss of medial column, calcaneal valgus, and prominence of the navicular tuberosity medially. In this particular case, custom functional orthotics are recommended for the treatment of calcaneal valgus and posterior tibial tendon dysfunction. These devices will allow the patient to ambulate in a more neutral position, reducing calcaneal valgus, and alleviating pain and strain from the posterior tibial tendon insertion. For these reasons, the requested custom orthotic inserts are medically necessary for the treatment of the patients medical condition. 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 podiatry 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 surgery to remove an ovarian cyst. This patient has a prior history of ovarian cancer and she now presents with an enlarging, complex left ovarian cyst that is greater than 10 cm. The size and complexity of the mass meet commonly accepted guidelines for surgical removal of the cyst. The fact that the patient has a normal CA125 is reassuring, but not a replacement for moving toward surgery. The patients hemoglobin A1C is not a reason to delay surgery. Based on the American College of Obstetricians and Gynecologists (ACOG) guideline, the removal of this patients symptomatic ovarian cyst is appropriate. Accordingly, the requested surgery to remove an ovarian cyst is medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested sclerotherapy for treatment of her status post removal of neuroma.  Findings:  Two physician reviewers found that one surgery was done using a dorsal approach, and the second surgery involved the plantar approach commonly done for recurrent neuroma. In this clinical situation, the requested sclerotherapy is likely to be the most efficacious treatment alternative.  Based on the submitted medical records, sclerosing injections are likely to be beneficial for the treatment of her condition.  As noted by the provider, there is a lack of treatment options for this patient.  All told, sclerotherapy is likely to be the most beneficial treatment in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine. Findings:  Three physician reviewers found that This patient has had chronic intractable migraine. The most recent and largest (and therefore most likely valid) studies of Botox as migraine preventive show benefit in patients with chronic migraine, even with ongoing medication overuse. Thus, there is adequate evidence that Botox is useful in a subset of migraine patients. It is reasonable to attempt treatment with Botox in patients who have failed adequate trials of multiple standard preventive therapies. This patient has had trials of standard preventives, without sufficient success. She has had ongoing benefit with Botox therapy, and thus, it can be concluded that Botox is likely to be of greater benefit than standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  Three physician reviewers found that although TMS is a fairly new treatment technology, the literature supporting TMS continues to grow. The efficacy of TMS may be greater than originally reported (Schutter; and Gross, et al.), as more recent studies are reporting more conclusive findings in well-developed studies (George, et al.; and Demitrack, et al.). A study by Ueyama and colleagues demonstrated hippocampal neurogenesis in rats, which is a phenomenon commonly seen in psychotropic medication and electroconvulsive therapy. TMS was approved by the Food and Drug Administration (FDA) in 2008. Subsequent to FDA clearance, the American Psychiatric Association (APA) also endorsed the use of TMS for the acute treatment phase of major depressive disorder. This endorsement by the APA makes TMS a standard treatment for major depressive disorder. The evidence provided in the peer reviewed medical literature, coupled with the patients clinical history indicates that the use of TMS in this patients case is likely to be more beneficial for treatment of the patients medical condition than any other standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female with neuropathic pain in her feet and a clinical diagnosis of tarsal tunnel syndrome has been made. The record did not include evidence of electro-diagnostic testing to confirm or disprove a diagnosis of polyneuropathy versus focal entrapment neuropathies. The patient is said to have failed treatment with Neurontin at an unspecified dosage and it is not noted whether she failed due to side-effects or lack of benefit at the maximal dosage. The patient appears to be tolerating Lyrica and indicates a benefit in reduction of pain symptoms. The patients provider indicates there is less than complete relief of the patients symptoms with Lyrica, and other than Neurontin, there is no indication other medications have been utilized for treatment of the patients peripheral neuropathic pain. The patients request for reimbursement and prospective authorization of Lyrica was denied by the Health Plan based upon a determination that the medication is not medically necessary.The patient has a diagnosis of neuropathic pain disorder which may represent bilateral focal mononeuropathies (tarsal tunnel) or an idiopathic polyneuropathy. There are no medications specifically approved for either condition and a review of the literature did not reveal relevant studies involving Lyrica. However, medications useful for the treatment of diabetic polyneuropathy are often useful in the treatment of polyneuropathies from other causes as well as idiopathic polyneuropathy. Diabetic neuropathic pain is potentially responsive to tricyclic agents, Neurontin, or opiates. A treatment approach for a case such as this one can reasonably be extrapolated from data and experience with diabetic neuropathy. If Neurontin were to be halted with an absence of side-effects, it could be re-tried, and titrated as high as 1800mg per day or to the point of benefit or failure due to side-effects. A trial of tricyclic medications or opiates at bedtime may also be helpful. These first-line medications should be shown to be ineffective before on-going management of the patients neuropathic pain with Lyrica is appropriate.Based upon the information set forth above, I have determined the medication at issue was/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 59-year-old male enrollee has requested a dermatology procedure to remove skin growths for the treatment of his atypical nevus. Findings:  The physician reviewer found that there is nothing in the records provided to suggest that the patient is experiencing any symptoms as a result of the cyst. The records suggest that any lesion encountered by the patients treating dermatologist thus far has been benign. Removal of the cyst in the absence of any symptomatology would be considered a cosmetic procedure.
Appeal type: Urgent Care
Decision: Upheld

The parent of a five-year-old female enrollee has requested an emergency room visit for the treatment of the enrollees ear pain. Findings:  The physician reviewer found that the Health Plan provides emergency services when medically necessary. An emergent medical condition is defined as acute symptoms of such severity that a prudent layperson would believe the absence of immediate medical attention would result in placing the patients health in serious jeopardy. This patient had been suffering from an earache since the morning in question. She was not noted to be in severe pain, and she did not require any pain control in the emergency department. Otitis media is commonly viral in nature. Antibiotics are often prescribed to allow for the possibility that the infection is bacterial in nature. However, the rapidity with which a patient receives antibiotics had not been shown to affect the rate of tympanic membrane rupture. While this patients symptoms likely required medical evaluation, this could have been provided on a less urgent basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Facial Feminization Surgeries.Ainsworth and Spiegel have demonstrated that facial feminization surgery, like genital surgery, is associated with improved mental health-related quality of life (Ainsworth, T., and Spiegel, J.). The World Professional Association for Transgender Health (WPATH) has stated that facial feminization surgery is medically necessary for some patients and may be a more important treatment for gender dysphoria than genital surgery. The WPATH has stated that non-genital surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals and that these interventions are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition (WPATH, 2016).In this case, the patient has submitted multiple documents that support her claim that the requested facial feminization surgeries are medically necessary. Records indicate that the patient has previously had gender reassignment surgery and reported no major disruptions with her transition. Records indicate that patient has been a regular and engaged client in therapy and has an established diagnosis of gender dysphoria. The provider has confirmed that the patient would like to continue her transition through facial feminization surgery in order to feel safer and more comfortable. Under these circumstances, the requested Facial Feminization Surgeries (CPT code 30420, Rhinoplasty, primary w/major septal repair; CPT code 21122, Genioplasty 2/> sliding osteotomies; CPT code 67900, Right repair of brow ptosis; CPT code 67900, Left repair of brow ptosis; CPT code 21175, Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead; CPT code 21139, Reduction forehead-contouring and setback of anterior frontal sinus wall; CPT code 20902, Bone graft, any donor area major/large; CPT code 61782, Stereotactic computer-assisted procedure/cranial, extradural; CPT code 21025, Excision of bone, mandible; CPT code 15733, Muscle, myocutaneous or fasciocutaneous flap-head and neck with named vascular pedicle; CPT code 15769, Grafting of autologous soft tissue by direct excision; and CPT code 15773, Grafting of autologous soft tissue by liposuction, each additional 25 cc injectate) are medically necessary to treat the patients medical condition (gender dysphoria).Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.