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

The patient has requested authorization and coverage for Matrix Autologous Chondrocyte Implantation (MACI). The U.S. Food and Drug Administration (FDA) indications for MACI states that this autologous cellular scaffold product is indicated for the repair of single or multiple symptomatic full thickness cartilage defects of the knee with or without bone involvement. Researchers found that MACI is an effective and durable treatment for full thickness cartilage defects in the knee. The authors reported that MACI provides satisfactory results in terms of pain relief and knee function rehabilitation, which appear to be sustained in the majority of patients according to long-term follow-up results. Researchers concluded that MACI demonstrated successful outcomes in 82% of patients over the long-term. However, increased patient age and lesion size greater than 4.5 x 4.5 cm were risk factors for a higher reoperation and failure rate. This patient presents with a five-month history of persistent left knee pain and occasional catching. The patient has documented functional limitations with activities of daily living. She is status post left knee arthroscopy with chondroplasty. Operative findings included a 1.5 x 1.5 cm full thickness chondral defect on the lateral femoral condyle. The patient has failed to improve despite reasonable and comprehensive conservative treatment. Current evidence-based medical literature supports the use of MACI as safe and effective with better long-term outcomes as compared to microfracture surgery in this clinical setting. Given these findings, the requested MACI is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Gel-One injection for the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient reported that relief from injections in the right knee had staved off a right total knee arthroplasty for ten years. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, along with the good prior response to viscosupplementation, the requested service is medically indicated. Therefore, a Gel-One injection for the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for OxyContin. OxyContin is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Guidelines provide specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. In addition, providers of opiate medication should document the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. This patients documentation does not demonstrate that the use of the prescribed opioid medication decreased the patients level of pain from one visit to the next. In addition, there is no noted functional improvement or improved pain noted during the duration of the prescription for OxyContin. For these reasons, OxyContin is not 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 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: Upheld

A 24-year-old male enrollee has requested individual psychiatric therapy, two to three times per week for treatment of her mood disorder and anxiety. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Effective psychotherapy is a trusted intervention in the treatment of patients with both depressive and anxiety disorders.  The current medical evidence supports aggressive treatment of mental health conditions, particularly in the acute phase of the illness in which once, twice or even thrice weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  In this patients case, there is no evidence of imminent threat due to the symptom burden or grave disability.  The current treatment plan includes weekly therapy and TMS.  Per the clinical notes, the patient has not demonstrated failure of the evidence-based treatment triad of TMS, psychopharmacotherapy and weekly individual therapy.  All told, individual psychiatric therapy, two to three times per week, is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of one-to-one applied behavioral analysis (ABA) therapy, three hours per week of social skills group therapy, and 2.5 hours per week of consultation and supervision. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address the patients delays in adaptive, social, behavioral and communication skill sets. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. The patient appears to have made progress in many areas as evidenced by the data from the progress reports. However, she continues to demonstrate significant delays in social skills and adaptive skillsets as measured across multiple domains. The patient continues to require a high level of behavioral support. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 authorization and coverage for Repatha Sureclick pen injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hyperlipidemia and hypertension.Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication in this clinical setting. Based on the records provided, the patient has known coronary disease and hyperlipidemia intolerant of two statin medications. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. According to the submitted records, this patient does not fit either of those criteria.  Specifically, there is no documentation to support the patients LDL is above goal while on an adequate trial of Zetia medication. In addition, other statin medications, such as pitavastatin and fluvastatin, have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. For these reasons, the request for Repatha Sureclick pen injector has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stem cell fat grafting for treatment of the enrollees non-healing wound. Findings:  The 3 physician reviewers found that Although there is some evidence of benefit with stem cell fat grafting in irradiated wounds, specifically with respect to radiation changes following breast reconstruction, it is unclear if this same benefit could be expected with an irradiated open wound. According to colleagues Although autologous fat grafting has been shown to improve the quality and regenerative potential of chronically scarred tissues and burn scars, the effect on wound healing of chronic wounds and early-stage pressure ulcers has only been reported on sporadically. In addition, the American Society of Plastic Surgeons (ASPS) noted that Based on a review of the current literature and a lack of strong data, the task force cannot make specific recommendations for the clinical use of fat grafts.  Although there may be a possible benefit for the reparative potential of stem cell fat grafting, there is a lack of clinical evidence to support its use in this clinical setting. Therefore, the request for stem cell fat grafting is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the requested service is 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 reviewer number one 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.Physician reviewer number two is board certified in 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 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: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested gene test PCA3 expression test for evaluation of his elevated prostate specific antigen (PSA) and enlarged prostate.  Findings:  Three physician reviewers found that clinical studies have not demonstrated that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. If clinically indicated, repeating the biopsy or saturation biopsy may be useful if prior biopsies are negative. The records indicate that this patients enlarged prostate and elevated PSA levels was appropriately evaluated with biopsy, which was negative, and free PSA level monitoring. Consistent with these findings, the PCA3 testing provided to this patient was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested a reduction mammaplasty for treatment of her macromastia. Findings:  The physician reviewer found that breast hypertrophy/macromastia is an abnormal enlargement of the breast gland. This patient is documented to have DDD sized breasts which is confirmed on the photographs. In addition, she has significant asymmetry in the volume of the breasts. The photographs demonstrate asymmetric abnormal enlargement that can be considered a developmental abnormality or a result of obesity, which can be considered a disease. However, there is minimal supporting medical documentation from the requesting provider to adequately define a functional deficit. By evaluation of the photographs, the patient has significant macromastia out of proportion to her body habitus. This is an abnormal appearance. The asymmetry contributes to this as well. Breast reduction is well recognized to address this and create a more normal appearance. The patient has significant macromastia that is asymmetric. Thus, a breast reduction would be expected to offer a significant improvement in the abnormal appearance of the patient and should be considered reconstructive in nature and therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Oncotype Dx prostate cancer assay provided for evaluation of the enrollees prostate cancer. Findings: Three physician reviewers found that the Oncotype Dx prostate cancer assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score is suggestive of a more favorable biology and less aggressive disease. This test may be utilized to counsel patients regarding the best course of therapy in newly diagnosed low or low-intermediate prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state that, retrospective case cohort studies have shown that these assays provide prognostic information independent of NCCN risk groups. However, the NCCN cautions that there is a lack of randomized controlled trials to confirm the utility of these tests and comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer. A guideline from the American Society for Clinical Oncology (ASCO) similarly found that prospective validation of these tests is needed to assess their impact on patient outcomes such as survival. Overall, there is limited data on clinical outcomes to currently support routine use of Oncotype Dx in this clinical setting. Thus, the Oncotype Dx prostate cancer assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician 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: All three physician reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested monthly intravenous immunoglobulin (IVIG) for treatment of the enrollees common variable immunodeficiency (CVID).  Findings: The physician reviewer found that as noted in the medical literature, IVIG infusion does possess risk, but this is reduced in patients receiving chronic infusions of replacement doses. Stiehm described that systemic adverse reactions can be immediate (60% of reactions) occurring within six hours of an infusion, delayed (40% of reactions) occurring six hours one week after an infusion, and late (less than 1% of reactions), occurring weeks and months after an infusion. Immediate systemic reactions such as head and body aches, chills and fever are usually mild and readily treatable. Immediate anaphylactic and anaphylactic reactions are uncommon. The most common delayed systemic reaction is persistent headache. Brennan and colleagues reported that no severe reactions occurred and the reaction rate was low at 0.8%. This patient presents with presumed CVID and possible connective tissue disorder but has normal labs. The patient has been receiving replacement immunoglobulin therapy for 26 years. Per the patient, she can only receive this infusion over two days and in a hospital setting due to previous anaphylaxis. However, the medical records provided for review fail to document any adverse reactions to prior infusions. In addition, since she has been receiving therapy for many years, her overall risk with recurrent infusions is low. As such, the request for monthly IVIG treatments to be provided in a hospital based center is not medically necessary for treatment of this patients medical condition.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 internal medicine with sub-specialty certifications in allergy and immunology and 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

The parents of an eight-year-old female enrollee have requested for Nutropin therapy for treatment of the enrollees growth failure/short stature. Findings:  The physician reviewer found that the patient does have a subnormal growth rate and if the subnormal growth rate continues this estimate may need to be revised downwards. However, based upon the available information this patient has a predicted adult height outside of the Food and Drug Administration (FDA) guidelines for growth hormone therapy for treatment of idiopathic short stature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lazanda nasal spray. This patient has a history of lumbar post-laminectomy syndrome with back pain that radiates into the right lower extremity pain. She is currently taking methocarbamol, OxyContin, Soma, and Tramadol for pain control and uses Lazanda nasal spray for breakthrough pain. The patient has been unable to tolerate oral medications for breakthrough pain due to vomiting and patches due to skin sensitivity. The patient has requested treatment with Lazanda nasal spray. The U.S. Food and Drug Administration (FDA) states that, Lazanda is an opioid agonist indicated for the management of breakthrough pain in cancer patients 18 years of age and older who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. The FDA has not approved this medication for non-cancer pain conditions such as lumbar post-laminectomy syndrome. The American Academy of Neurology (AAN) recommend opioids for chronic low back pain as a short-term therapy. The AAN noted that, opioid treatment should be limited to a finite course over a few weeks given the absence of evidence to suggest any long-term pain improvement from its use. A study concluded that, that, chronic opioid therapy for non-cancer paindoes not reliably improve long-term pain and function scores. The American Academy of Neurology (AAN) recommend opioids for chronic low back pain as a short-term therapy. The AAN noted that, opioid treatment should be limited to a finite course over a few weeks given the absence of evidence to suggest any long-term pain improvement from its use. Further, there is a paucity of medical literature demonstrating the safety and efficacy of Lazanda for patients with non-cancer pain. Given these findings, Lazanda nasal spray is not medically necessary for 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 anesthesiology with subspecialty certification in pain management 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.