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 Qelbree 200 mg capsule extended release. The records provided for review document that this patient has been diagnosed with attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive type. The provider noted that the patient was previously treated with Qelbree with substantial benefit. Given the support for the patients diagnosis of ADHD, the patient is an appropriate candidate for treatment. However, given patients concomitant anxiety and ADHD as well as his history of severe substance use, treatment with stimulants for adult ADHD is contraindicated. Per the records, the patient has benefited from treatment with Qelbree 200 mg without any medication adverse effects. The patients provider has recommended continued treatment with Qelbree. Edinoff and colleagues noted that Qelbrees mechanism of action, clinical effects, and limited side effect profile point toward the drugs relevance in the treatment of ADHD. Singh and colleagues performed a meta-analysis to determine the safety and efficacy of Qelbree in the management of patients with ADHD. The authors reported that Qelbree was found to be significantly superior to placebo in 1,605 patients with ADHD across five randomized clinical trials. Moreover, treatment with Qelbree is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this support, continued treatment with Qelbree is appropriate and consistent with the recommendations in the medical literature. Therefore, the requested Qelbree 200 mg capsule extended release 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 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.Findings:  Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: An enrollee has requested authorization and coverage for Otezla 1-30 mg twice per day for treatment of the enrollees plaque psoriasis. Findings: The physician reviewer found that this patient has widespread plaque psoriasis affecting more than 40% of his body surface area. He has tried and failed therapy with topical steroids and ultraviolet B treatment. He has a history of untreated latent tuberculosis. Injectable biologic agents including Enbrel, Humira, and Stelara carry risks of infection and reactivation of latent tuberculosis, which this patient has been shown to have. Moreover, Otezla is considered to be a first-line oral agent for the treatment of plaque psoriasis for use in this clinical setting. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic distal bypass. Findings:  The physician reviewer found that The available documentation indicates that this patient is a candidate for surgical intervention to lengthen the bypass limb. The patient is status post Roux-en-Y gastric bypass as well as revision surgery. However, the patient continues to be morbidly obese with a body mass index (BMI) over 50 kg/m2. Moreover, the patient has comorbidities including diabetes, hypertension, hyperlipidemia, and fatty liver. Given the patients BMI and comorbidities, the requested lengthening of the limb is likely to provide the patient with the best health outcome. El Ansari and Elhag noted that bariatric surgery remains effective and durable for treating obesity and ameliorating or resolving the obesity-related comorbidities. The authors commented that revision bariatric surgery is indicated to address surgical complications, weight regain or insufficient weight loss. In this patients clinical setting of weight regain after Roux-en-Y gastric bypass and revision, the requested laparoscopic distal bypass is likely to be more beneficial than other surgical approaches. All told, the requested laparoscopic distal bypass is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested laparoscopic distal bypass is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: 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 1 is board certified in general surgery and is actively practicing. Physician reviewer 2 is board certified in general surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery and is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 liquid biopsy. Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component in improving the care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with Guardant360 is indicated in this clinical setting. Thus, the Guardant360 liquid biopsy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that since standard guidelines do not include Guardant360, the Guardant360 liquid biopsy was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni for 12 weeks. Findings:  The physician reviewer found that according to the most 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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 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

A 39-year-old female enrollee has requested for a wireless capsule endoscopy for evaluation of her abdominal pain.  Findings:  The physician reviewer found that wireless capsule endoscopy (WCE) is a major advance in visualization of the small intestine. WCE offers the following potential advantages over other more broadly used imaging techniques, Iit offers the potential to directly visualize the entire mucosal surface of the  small bowel. It has the ability to detect subtle superficial lesions not evident on traditional contrast radiographs. It is less invasive than conventional endoscopy. It does not require sedation or anesthesia. It is well accepted by patients. WCE is approved for the evaluation of patients with obscure GI bleeding, iron deficiency anemia with negative EGD and colonoscopy, and patients with suspected Crohn's disease or other small bowel diseases with a negative small bowel series.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old male with hepatitis B who was initially treated with lamivudine in November 2000. His viral count became detectable in February 2004 and he was placed on adefovir. After starting treatment with adefovir his liver enzymes and DNA level are negative. The patients provider has recommended the patient continue taking adefovir. The Health Plan has denied this request.The patient should remain on adefovir until his hepatitis B surface Ag converts to negative. There are many reports regarding the use and safety of adefovir for treatment of this patients condition. A recent report concluded that administration of adefovir in patients with lamivudine-resistant hepatitis B results in significant suppression of viral replication; however, continuous therapy will probably be required in order to maintain submission. Furthermore, discontinuing adefovir therapy could predispose the patient to fulminant hepatic failure. Based upon this information, I have determined the requested medication is 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: The parent of an enrollee has requested authorization and coverage for Omnitrope growth hormone therapy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. At issue in this case is whether the requested Omnitrope growth hormone is medically necessary for treatment of the patients medical condition. Pediatric Endocrine Society guidelines for the definition of idiopathic short stature have not been met. The patients height is 1.7 standard deviations below the mean for age and gender. The guideline definition is below 2.2 standard deviations below the mean for age and gender. There is no prediction of adult height based on bone ages that are younger than 6 years of age. It is unclear which method was used to calculate estimated adult predicted height of five feet five inches. The growth velocity of 7cm/year is an excellent growth velocity and completely normal, which makes the diagnosis of pathologic etiology of short stature unlikely. Therefore, the requested Omnitrope growth hormone is not medically necessary.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 pediatrics with subspecialty certification in pediatric endocrinology 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 parent of a 17-year-old male enrollee has requested for residential treatment care for treatment of the enrollees substance abuse and major depression. Findings:  The physician reviewer found that the patient could have been treated at a lesser level of intensity at that time, such as partial hospitalization.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 29-year-old female with a body mass index (BMI) of 43, with comorbid conditions including diabetes, hypertension, and urinary stress incontinence. The submitted information does not include evidence that the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The patient has requested authorization and coverage for gastric banding. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.With a BMI of 43 and multiple comorbid conditions the patient meets nationally accepted criteria for weight loss surgery. However, gastric band surgery is not considered standard of care. Furthermore, gastric banding is known to have higher complications and greater risk than other weight loss procedures. This patient can be appropriately and effectively treated through Roux-en-Y gastric bypass. However, although medically the patient meets criteria for consideration of Roux-en-Y gastric bypass, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that although gastric banding is not medically necessary for treatment of the patients medical condition, Roux-en-Y gastric bypass is medically necessary depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be partially overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, Roux-en-Y gastric bypass should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, Roux-en-Y gastric bypass should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested partial hospitalization services for the treatment of her bulimia nervosa and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient met American Psychiatric Association (APA) criteria for partial hospitalization on the dates of service at issue. She had daily repetitive thoughts about disordered eating and required structure and support to adhere to weight gain. She had skipped meals while at home on the weekend. She also had significant co-morbid psychiatric disorders impacting her recovery. All told, the patients clinical condition required the structure and monitoring available in a partial hospitalization setting during the period at issue. Without these services, there was significant risk of relapse and/or deterioration.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rinvoq (upadacitinib) extended 24-hour release 15 mg. Findings:  The physician reviewer found that In this case, the patient has rheumatoid arthritis and reported good response to Rinvoq. Given that the documentation shows that the patient has tried and failed multiple TNF inhibitors, a trial of another TNF inhibitor when she has had good response to another class of medications is not medically indicated. Therefore, Rinvoq (upadacitinib) extended 24-hour release 15 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 enrollee is requesting authorization and coverage for a power scooter. The enrollee has a history of degenerative disc disease, osteoarthritis of the spine, arthritis of both hips, and bilateral rotator cuff syndrome. She has had a right hip replacement, left knee replacement, carpal tunnel release, and hernia repair. She has a 4-wheeled walker with a seat, but reports she can only ambulate short distances without resting. The enrollee reports she requires a scooter to enable movement inside and outside of her home. Her orthopedic physician reports the enrollee is unable to use her upper extremities to push a standard wheelchair. Motorized scooters are only recommended for a very specific category of individuals; those with severe mobility impairments, an inability to ambulate with the assistance of a cane, walker, or other assistive device, and an inability to propel a manual wheelchair. These individuals must also have shown an inadequate response to multiple other treatments, including medications, aerobic exercise, strengthening exercise, weight loss, aquatic therapy, injections, joint replacement, and other surgeries. Reliance on a motorized scooter can increase the risk of further deconditioning and worsening of a enrollees condition if used inappropriately. A physical therapy evaluation shows the enrollee is able to ambulate under her own power in the house and uses a 4-wheeled walker, with a seat for community ambulation.  She has limited, but functional, use of both arms.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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 similar medical condition.