Persius/imr-appeals huggingface dataset:
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
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara. Current medical literature supports the use of Stelara in this case. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. One large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A recent study demonstrated that a majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this patient with primary nonresponse to anti-TNF medication (Humira), a medication with an alternative mechanism of action, such as Stelara, is more appropriate to control disease and to prevent further complications. For these reasons, Stelara is medically necessary for the treatment of this patients Crohns disease.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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection (hyaluronan) for treatment of knee pain due to osteoarthritis. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Researchers have noted that medical guidelines recommend intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, other researchers have conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for interferon alfa 2b injections. The submitted documentation supports the medical necessity of the requested medication. A large case series of 127 patients by researchers demonstrated an overall 54% response rate with a mean 9 degree improvement in curvature in all patients. The study concluded that intralesional therapy with interferon alfa 2b continues to be a viable treatment option for Peyronies disease with data consistently showing improvements in disease characteristics. The current medical evidence supports intralesional interferon alfa 2b for nonoperative treatment of Peyronies disease. Therefore, interferon alfa 2b injections 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 urology 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.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG). Central to the idea of PANDAS is the concept that after Group A beta-hemolytic streptococcal (GABHS) infection, antibodies are generated that cross-react with antigens present in the basal ganglia and related structures. This in turn causes pathologic derangement of poly-synaptic pathways that subserve both cognitive, emotional and motor functions frequently associated with obsessive compulsive disorder and other neuropsychiatric disorders. In the medical literature, researchers reported on a clinical trial that showed no difference between IVIG and placebo in the blinded phase for pediatric patients with a purported diagnosis of PANDAS. All told, the current medical literature does not support the requested IVIG as medically necessary for treatment of this patients medical condition. 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 and neurology with special qualification in child 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. Review of the submitted evidence demonstrates that the requested Xeljanz 5 mg tablet is medically necessary for treatment of the patients medical condition. In this case, the patient has seronegative rheumatoid arthritis, Sjogren's syndrome and a positive ANA. The submitted documentation demonstrates the patient has failed methotrexate and hydroxychloroquine. Further, there is evidence the patient has previously done well with Xeljanz with no evidence of synovitis. Given the patients history of positive ANA, a tumor necrosis factor inhibitor (TNFi) such as Enbrel or Humira would not be recommended. Therefore, the requested Xeljanz 5 mg tablet is medically necessary.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.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Lyrica. The Health Plan has denied this request on the basis that the requested medication is not medically necessary for treatment of the enrollee's foot pain. Review of the submitted documentation supports the medical necessity of Lyrica in this clinical setting. The patient presents with traumatic neuropathy with motor involvement. The submitted records reveal the patient has EMG-confirmed peroneal neuropathy (sensorimotor). He has a history of treatment with gabapentin. Gabapentin is contraindicated in this patient as it caused mental confusion, which is a known side effect of the drug. As such, gabapentin is not appropriate for this patient due to well recognized neurologic side effects. Lyrica has been approved by the U.S. Food and Drug Administration for treatment of neuropathic pain. As such, the requested medication is medically reasonable and necessary for treatment of this patients medical condition.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 pain medicine and anesthesiology 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Depend brand adult diapers. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There are several types of urinary incontinence, and there is significant overlap in the conditions that cause urinary leakage. The risks for urinary incontinence increase with age, female gender, decrease in estrogen levels at menopause, obesity, smoking, chronic constipation, neurologic disorders and diabetes mellitus.  The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Patients often use incontinence pads when leaking is not controlled by medications or surgical treatments.  In this case, the patient is requesting a specific brand of adult briefs or incontinence pads. However, there is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. Therefore, the requested Depend brand adult diapers are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Saxenda. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity. The submitted documentation does not support the medical necessity of the requested medication. Saxenda is approved for the treatment of obesity. It is used in adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index greater than 30 kg/m2 or greater than 27 kg/m2 in the presence of at least one weight-related comorbid condition, including hypertension, type II diabetes mellitus, and/or dyslipidemia. Initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention consisting of a combination of diet, exercise, and behavioral modification. Per the medical evidence, patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with an initial body mass index greater than 30 kg/m2 or a body mass index of 27 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction, and increased physical activity to achieve weight loss goals. Additionally, the requested non-formulary drug, Saxenda, would not be more effective than the Health Plans formulary drugs, phentermine, benzphetamine, diethylpropion, and phendimetrazine.  There is a lack of studies that demonstrate that Saxenda is more effective than the listed formulary drugs. Therefore, Saxenda 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 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.
Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for immunotherapy with nivolumab (Opdivo). The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees grade IV glioblastoma. Although multiple trials are testing various forms of immunotherapy in patients with glioblastoma, published data remain limited. In a phase I trial investigating the safety of monotherapy or combination therapy with two checkpoint inhibitors, 40 patients received either Opdivo with or without ipilimumab. Overall, monotherapy with Opdivo was better tolerated than combination therapy. However, the authors concluded that further studies are needed to help select patients most likely to respond to checkpoint inhibitor immunotherapy. Available standard therapies include retreatment with temozolomide and low-intensity alternating electric fields, which have more data to support them than Opdivo in this clinical setting. Accordingly, the requested Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Opdivo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT 0232T). Findings:  Two of the three physician reviewers found this patient presented with a history of chronic bilateral knee pain. There was imaging evidence of bilateral lateral meniscus tears. Prior hyaluronic acid injections had provided two years of good relief. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure was not submitted. The procedure report documented bilateral knee platelet-rich plasma injections were performed for the diagnoses of bilateral meniscal tears and knee pain. There is an absence of large well-designed clinical studies to support the safety and efficacy of platelet-rich plasma in knee meniscal and cartilage disorders. The use of platelet-rich plasma injections is not supported in this clinical setting. In this patients case, the evidence does not support the use of platelet-rich plasma injections over other conservative treatment options. In sum, platelet-rich plasma injections were not likely to have been more effective than other treatment modalities. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for stroller repairs for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that the patients stroller is the primary source of mobility that the patient uses. The patient is quadriplegic and has cerebral palsy. Thus, the use of the stroller is mandatory for proper transport of the patient for activities of daily living (ADLs) and for routine daily travel. Based on the review of the current medical literature, the stroller repairs provided were medically necessary for treatment of this patients medical condition. 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of neurologic disorder. Findings:  The documentation provided does not support the superior efficacy of the requested services. While there is documentation that this patient has been diagnosed with Lyme disease, the available records do not substantiate conclusively the presence of Lyme disease or any other infection in this patient.  However, even if the records support the diagnosis of Lyme disease in this patient, peer reviewed literature supports treatment for no more than four weeks with any antibiotics. This patients request is for intravenous ceftriaxone for a period in excess of four weeks. Based on the documentation provided as well as the medical literature, additional ceftriaxone sodium injection (HCPCS-J0696) with accompanying supplies and home infusion nursing visits (CPT 99601) is not likely to be of greater benefit when compared to the available standard duration for treatment of this patients medical condition. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  Two reviewers are board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. One reviewer is board certified in internal medicine with expertise in Lyme disease. 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.