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

 The patient has requested authorization and coverage for Gilenya capsules. Gilenya is a U.S. Food and Drug Administration (FDA) approved therapy for the treatment of RRMS. Gilenya was the first in class disease modifying treatment in multiple sclerosis that acts as sphingosine-1-phosphate receptor agonist. Since approval in 2010, there is a growing experience with Gilenya use in clinical practice (Ziemssen, et al.). This patient has been stable on ocrelizumab, but has developed side effects. The provider has recommended a change in therapy to avoid treatment related complications. Given these findings, the requested Gilenya capsules are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx Sensoready (300 mg) Subcutaneous Auto Injector 150 mg/ml (starter and maintenance doses).In this case, the patient suffers from chronic, widespread plaque psoriasis and has failed to respond to treatment with class 1 topical corticosteroids and UV phototherapy. The requested medication, Cosentyx, is a generally accepted medical pharmacologic treatment of chronic plaque type psoriasis. The alternative medication methotrexate would not be a good choice for a patient who drinks alcohol regularly, and cyclosporine, another alternative, is a temporary treatment for psoriasis that is not to be used chronically, and this is a chronic disease. Under these circumstances, the requested medication, Cosentyx Sensoready (300 mg) Subcutaneous Auto Injector 150 mg/ml (starter and maintenance doses), is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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 42-year-old female enrollee has requested acute psychiatric inpatient hospitalization services for treatment of her behavioral health issues.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) practice guidelines, a careful assessment of the patients risk for suicide is critical. The lack of a risk assessment and failure to place the patient on suicide precautions thus is inconsistent with the APA guideline for management of patients with bipolar disorder and those with suicidal behavior. There is no indication that the patient requires a 24 hour containment and skilled monitoring. Thus, the medical necessity for inpatient services is not supported by the data reviewed as it appears that she can be safely and effectively managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. Colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

An enrollee has requested authorization and coverage of Mavyret for eight weeks. Findings:  The physician reviewer found that According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Medical Necessity
Decision: Upheld

The parents of a five-year-old male enrollee requested authorization and coverage for speech therapy for treatment of the enrollee's otis media.  The health plan has denied this request. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested speech therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Allergen Specific IgG testing for the evaluation of the enrollees dyspepsia.  Findings:  The physician reviewers found that there is a lack of high-quality peer-reviewed literature supporting the use of IgG food allergy testing for the evaluation of gastrointestinal symptoms. In addition, a number of national and international medical societies have expressed strong recommendations against the use of this testing and concern about its ongoing use for this indication. The American Academy of Allergy, Asthma and Immunology (AAAAI) guidelines state that IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed. The AAAAI guideline for management of adverse reactions to foods states that measurement of specific IgG antibodies to foods is unproven as a diagnostic tool. The European Academy of Allergy and Clinical Immunology reports that as many serum samples show positive IgG4 results without corresponding clinical symptoms, and due to the lack of any controlled studies on the diagnostic value of IgG4 testing in food allergy, such testing does not have value. Given the lack of high-quality trials, and the issuance of broad consensus statements against use of the testing, the Allergen Specific IgG testing  was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the testing at issue was 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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: Upheld

The parent of a 14-year-old female enrollee has requested acute inpatient treatment services, partial hospital program services, as well as prospective services at either level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the medical records submitted do not support the medical necessity of acute inpatient services for the dates of service at issue. While the patient continued to be underweight, the records indicate that she was stable for partial hospitalization program (PHP) level of care as of her admission date, and in fact, this was the recommended level of care at the time of the patients planned discharge from the hospital. The record does not reflect her ideal body weight, but she had gained four pounds over the preceding week and a half and there was no indication of physiological compromise. Therefore, American Psychiatric Association (APA) and National Eating Disorders Association (NEDA) criteria for the acute residential treatment center level of care were not met as there was no evidence that the patient was psychiatrically impaired and unable to respond to PHP or outpatient treatment. PHP was the recommended level of care and the information submitted does not indicate that the patient could not have been safely and effectively treated at this level as of the admission date. In regards to partial hospitalization program services provided the following month, there was no clinical data submitted for the services provided during this time period. Therefore, the records fail to support the contention that the patient was in need of daily assessment of physiological and mental status; that her eating disorder was impairing her functioning to the extent that she was unable to function in normal social educational or vocational situations; that she was engaging in daily binge eating, purging, fasting, or other pathogenic weight control techniques; or that she was seriously underweight and in need of structured programming to gain a significant amount of weight. Thus, there is no evidence that the patient met APA or NEDA medically necessity criteria for PHP services during this time period. The patient clearly has been struggling with a serious eating disorder and was significantly compromised to the point of requiring inpatient treatment for approximately one month. Eating disorders tend to be chronic in nature. At the time of her planned discharge, the patient continued to be underweight. However, there has been no recent data submitted which establishes a current need for treatment with a reasonable degree of certainty. Medically necessary services at any given time will depend on the patients current psychiatric and medical condition, along with any additional co-morbid conditions which may arise. Given the absence of evidence of such, the medical necessity of future acute inpatient or PHP levels of care has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for anastrozole for treatment of the enrollees low testosterone and elevated estradiol levels. Findings:  The physician reviewer found that this patient presents with low testosterone levels, elevated estradiol and hypogonadal symptoms due to secondary hypogonadism. Conventional treatment with testosterone replacement will further diminish his ability to produce endogenous testosterone and sperm, resulting in infertility and dependency on this hormone to maintain the benefits of normal levels therapy. Anastrozole has been used in male hypogonadism based on studies available in the peer-reviewed medical literature. Studies have shown that anastrozole is effective in decreasing estradiol in male patients with hypogonadism. In addition, treatment with anastrozole has been shown to increase testosterone levels and seminal parameters in this patient population. Given this support, the requested anastrozole is medically necessary for treatment of this patients symptomatic hypogonadism, low testosterone levels and high estradiol levels. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion using the IFuse Implant system for treatment of the enrollees SI joint pain. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Colleagues compared SI joint fusion using triangular titanium implants to nonsurgical management. The conclusions were that at six-month follow-up the minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the peer-reviewed literature, the request for minimally invasive right SI joint fusion is clinically indicated for this patient. Furthermore, the proposed IFuse Implant system is proven to be safe and effective in multiple documented studies. Therefore, the requested right SI joint fusion using the IFuse Implant system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the requested services are likely to be more beneficial for treatment 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested admission to an inpatient residential chemical dependency program for treatment chemical dependency. Findings:  The physician reviewer found that he records provided for review document that this patient received inpatient detoxification which was successful in tapering her off opiates and benzodiazepines. There is no evidence of withdrawals or post-acute withdrawals. Based upon the records provided, the patient is currently medically and psychiatrically stable with regard to her comorbid health conditions, which are chronic in nature and do not require residential level of care. Further, there is no documentation of emotional, behavioral, or cognitive factors which require the intensity of 24-hour monitoring and supervision. The standard of care in this setting includes participation in a 12-step program and outpatient treatment in a setting such as cognitive behavioral therapy (CBT), which can teach coping skills to manage chronic pain. Final Result: The reviewer determined that the requested services 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 psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks). Findings:  The physician reviewer found that Pace and colleagues report, Soft tissue atrophy and skin hypopigmentation are rare but potentially distressing complications of corticosteroid injections (CIs). These changes usually manifest within several months of the steroid injection and will often resolve within one year. Guigni and colleagues state, Our results provide evidence for skeletal muscle atrophy and mitochondrial rarefaction in breast cancer patients that may be linked to the mitotoxic effects of chemotherapeutics. In this case, the patient reports long-standing indentations on her buttocks from childhood that have worsened post chemotherapy treatment, and her provider has noted a possibility that the appearance of her buttocks may be related to chemotherapy. While instances of fat tissue atrophy with corticosteroid injections and of skeletal muscle atrophy with chemotherapy have been reported, current medical literature does not support a relation of chemotherapy to localized fat atrophy, and the records did not document that the patient sustained a single site increase in localized fat atrophy as a result of generalized breast cancer chemotherapy. Therefore, in this clinical setting, liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks) is not medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, while it is not clear that the depression on the patients buttocks constitutes an abnormal structure of the body, it does not cause a functional loss. The appearance of the buttocks is normal, and the requested service would likely result in minimal improvement in appearance. Accordingly, the requested liposuction (fat grafting of buttocks, using fatty tissue from the abdomen to fill in the buttocks) is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested Provigil for medical treatment of her multiple sclerosis related fatigue.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has fatigue, improved with Nuvigil, but with excessive insomnia.  Symptom management is important to quality of life in patients with chronic disorders such as multiple sclerosis.  Fatigue can be very limiting, and strategies to manage it, including lifestyle and pharmacologic care, are often necessary.  There is evidence in the medical literature supporting the use of Provigil in the treatment of fatigue in conditions such as multiple sclerosis.  Other medications, such as stimulants, have greater hazard and abuse potential.  All told, Provigil is medically indicated for the treatment of this patient.