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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoporosis. The provider noted that the patient sustained a left hip fracture, a right distal radius fracture, and a right femoral neck fracture in. All fractures occurred after falls. The patient has not received prior therapy for osteoporosis. The provider noted a dual-energy x-ray absorptiometry (DEXA) scan revealed a distal radius T score of -2.3. The patients vitamin D level was noted to be 41. The patient has requested authorization and coverage for romosozumab (Evenity) injections. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether romosozumab (Evenity) injections are medically necessary for the treatment of the patients medical condition. Researchers reported, Romosozumab is a monoclonal antibody that binds to and inhibits sclerostin, increases bone formation, and decreases bone resorption. The authors noted, The U.S. Food and Drug Administration (FDA) approved Evenity (romosozumab) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Authors reported, Clinical trials demonstrated that romosozumab markedly increased bone formation and therefore bone mineral density, and suppressed vertebral fractures compared with a placebo in postmenopausal women with osteoporosis. In this case, the patient has been diagnosed with osteoporosis with a recent history of a right femoral neck fracture. The medical evidence supports the requested medication in this clinical setting. Therefore, romosozumab (Evenity) injections are 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance transport. The records provided for review document that this patient had significant and rapid gastrointestinal bleeding requiring a large-volume blood transfusion of six units. The patient was found to have variceal bleeding, which is considered a medical emergency (Kim; Maruic, et al.). According to American Association for the Study of Liver Disease (AASLD) guidelines for the management of variceal bleeding, acute variceal hemorrhage is a medical emergency requiring intensive care, and endoscopy is done as soon as possible and not more than 12 hours after presentation. If a variceal source is confirmed, endoscopic variceal ligation should be performed. Based on these guidelines, the patient warranted both intensive care unit (ICU) services and immediate specialized endoscopic intervention, neither of which were available at the original facility. Therefore, an emergent transfer was warranted. Due to the high risk in variceal bleeding, the AASLD guidelines would support air transport in this patients case. A ground ambulance transfer would have taken too long, and an emergency could not have been adequately managed during transport. For these reasons, the air ambulance transport was medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic urethral lift, UroLift procedure.  Findings:  The physician reviewer found that Recent clinical trials have shown that the UroLift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate, the UroLift procedure is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. A recent prospective, randomized, multinational study by Sonksen and colleagues compared the outcome of prostatic urethral lift to transurethral resection of the prostate. The authors concluded that patients who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate. Thus, prostatic urethral lift, UroLift procedure is likely to be more effective than other treatment options. Final Result: Two of three 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 reviewers 1, 2 and 3 are board certified in urology 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 brand name medication, Tazorac Gel.   Findings: Guidelines state that tazarotene is a reasonable first-line treatment for palmar plantar psoriasis. The guidelines note, Topical tazarotene can be particularly helpful for palmar-plantar psoriasis and nail psoriasis. In this case, the patient has been prescribed Tazorac Gel to treat his plantar psoriasis. Per the submitted documentation, Tazorac Gel has been effective for this patient in the past. Therefore, brand name medication, Tazorac Gel, 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 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

The patient is a 40-year-old male with psoriasis, which has become progressively more extensive. Ultraviolet light treatment resulted in significant pain. Soriatane was ineffective and was discontinued due to elevated liver enzymes. The patients liver enzymes remain elevated. The patients dermatologist and primary care physician have recommended treatment with Enbrel injections. The Health Plan has denied coverage for Enbrel on the basis that it is not medically necessary.Methotrexate is absolutely contraindicated in patients with any evidence of liver dysfunction. In the early days of methotrexate treatment for psoriasis there were fatalities from liver failure as well as cases of permanent morbidity from liver damage. Furthermore, cyclosporine can result in liver damage, and hypertension and/or renal disease are not uncommon complications. As such, cyclosporin is not recommended and at the most, should be used for only a few months because of the potential side effects. Enbrel has none of the above-mentioned side effects and can be used on an ongoing basis. In light of the patients elevated liver enzymes, Enbrel is the most appropriate treatment for this patient and should be authorized.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services. Based on the records provided for review, by the date of the Health Plans denial, this patient did not require skilled nursing or rehabilitation services on a daily basis. The patient did not require skilled therapy to prevent deterioration with mobility or activities of daily living. She did not require skilled therapy to establish a safe and effective maintenance program. She did not require any skilled services on an inpatient basis at the SNF level of care. The patient did not have any parenteral medications, complex wound care, or nutrition given via a feeding tube. She received skilled care and improved. However, her function had plateaued and she did not require any further inpatient skilled rehabilitation services as her functional status was at or near her baseline. Given these findings, the SNF services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delays. Findings:  The physician reviewer found that the patient has an identified delay in his receptive language skills of 34 to 44% and a delay of 68 to 84% in his expressive language skills. Speech therapy is indicated with any delay greater than 25% (Feldman and Messick). Speech therapy has been shown to have a positive effect in children with expressive phonological and expressive vocabulary difficulties. Treatment for language disorders should be predicated primarily on the childs language profile and level of communication skills. (Feldman and Messick) Children who participate in speech and language treatment show greater improvements than those children who have no treatment (Messick and Feldman). Preschool children, with specific language impairments, demonstrated statistically greater improvement with intensive direct speech therapy when compared to no intervention or nursery-based intervention (Gallagher, et al.). All told, the requested speech therapy is medically necessary for treatment of the patients speech delays. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira. Current medical literature supports the requested Humira to be used as dual biologic therapy with Stelara for the treatment of this patients Crohns disease. The patients disease is severe and complicated by fistula. The patient has failed treatment with multiple primary therapeutic medication classes recommended by guidelines for the treatment of Crohns disease. In addition, the patient is already on dose-escalated Stelara. Several studies have assessed the use of dual biologic therapy including Stelara. In this case, the patient demonstrated improvement on Stelara, although colonoscopy showed ongoing inflammation and he has reported ongoing symptoms. A continuation of current therapy could result in additional complications of uncontrolled disease and the patients alternative options are limited. In this clinical setting, the requested therapy with Humira in combination with high-dose Stelara is appropriate for the treatment of this patients Crohns disease. Therefore, the requested Humira 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 internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lynparza 150 mg tablets. The National Comprehensive Cancer Network (NCCN) guidelines recognize that there is a lack of standard treatment options for recurrent anaplastic astrocytoma. Preliminary trials on the PARP inhibitor Lynparza have found efficacy with the use of Lynparza taken in combination with temozolomide. This patient has exhausted available standard therapies yet he retains a good performance status. Due to the IDH-mutant status, Avastin is unlikely to be effective. The data in the medical literature has demonstrated the efficacy and tolerability with the recommended regimen. Therefore, the requested Lynparza 150 mg tablets 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that  according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment recommendations, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment naive patients with HCV genotype 1. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks (Kowdley, et al). Therefore, Harvoni for 8 weeks is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested Armour thyroid medication for treatment of her hypothyroidism.  Findings:  The physician reviewer found that when monitoring and titrating thyroid hormone doses carefully to maintain a normal thyroid stimulating hormone (TSH) level, the result has been rewarding for most patients, and improved their well-being, health, energy, mental function and weight. The American Association of Clinical Endocrinologists and American Thyroid Association have cautioned against the use of T3 containing therapies, such as liothyronine and desiccated thyroid (Armour thyroid), even though these two medications are FDA approved for the treatment of hypothyroidism. However, some patients with hypothyroidism do not feel well on levothyroxine alone despite normal thyroid function tests. In a select patient population, addition of T3 to their therapies in the form of desiccated thyroid, to replace levothyroxine resulted in improvement (Biondi and Wartofsky). While the validity of the study is limited by methodological factors and there is no consensus in what combination of T3 is optimal, the authors concluded that there is a scientific basis that might explain the benefit reported by patients with the combination regimens including T3. On review of this patients medical records, she has responded better to Armour thyroid treatment than with levothyroxine alone. For these reasons, continuation of Armour thyroid treatment in this patient is medically necessary with the proper monitoring.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni and ribavirin for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  The guidelines state that cirrhotic patients are high priority for treatment.  Per the guidelines, cirrhotic treatment-experienced genotype 1 patients should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials.  All told, Harvoni and ribavirin for 12 weeks are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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: Overturned

The patient is a 32-year-old female who is 52 and 221 pounds with a body mass index (BMI) of 40.4. She has engaged in multiple attempts over the years to lose weight, all of which have failed. It does not appear the patient has obtained psychiatric clearance. The patient has requested authorization for gastric bypass surgery. The Health Plan has denied the request indicating gastric bypass surgery is not medically necessary. With a BMI of 40 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient 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, although medically the patient meets criteria for consideration of weight loss surgery, 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 the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cambia oral powder for treatment of the enrollees migraines. Findings: The physician reviewer found that Cambia is an oral solution diclofenac. The records provided for review document that this patient was treated with Toradol and Imitrex without significant benefit. The patient was subsequently treated with Cambia with substantial benefit. In the medical literature, Joshi and Rapoport reported that diclofenac oral solution may offer rapid and sustained pain relief for patients who do not achieve pain resolution with other medications. In addition, patients who experience central sensitization with allodynia may benefit from the cyclooxygenase-blocking activity of diclofenac, which is needed in this advanced phase of migraine. Garnock-Jones noted that diclofenac potassium powder was clinically efficacious and generally well tolerated in placebo controlled trials and was more effective than diclofenac potassium tablets with regard to the primary endpoint of two hour pain relief as well as in several important secondary endpoints. Given that this patient has been treated with Imitrex and Toradol without benefit and Cambia was beneficial to improve headaches as well as improve function, the requested Cambia oral powder is medically necessary for treatment of this patients migraines.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 sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male has requested past and future coverage for acute inpatient psychiatric care for treatment of his behavioral health issues.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) practice guidelines recommend outpatient treatment of bulimia nervosa, except when there are complicating factors such as serious medical problems, suicidal behavior, or psychosis. This patient requires monitoring for both his ongoing suicidal ideation and medical complications related to his malnutrition. He will continue to need to make use of the ongoing 24-hour treatment that can only be provided in an acute inpatient unit. Admission from the dates at issue and forward is appropriate to diagnose and treat the patients condition and cannot be provided safely in a less restrictive setting.