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

A 63-year-old male enrollee has requested Novolog Flex Pen and Lantus Solostar Pen medications for treatment of his diabetes mellitus type II.  Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the Novolog Flex Pen and Lantus Solostar Pen are medically necessary for this patient. There is no evidence that the patient will experience adverse consequences in the absence of the specific medications requested. While the insulin pens such as those requested by the patient are generally easier to use, there are alternate options available in this setting. For example, as has been suggested by the patients provider, the insulin can be pre-loaded into a syringe to avoid breakage; another option would be to carry the insulin vials in a case. In the absence of evidence of a medically valid indication for the use of Novolog Flex Pen and Lantus Solostar Pen, the medical necessity of the proposed medications is not established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in the left knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of relief with viscosupplementation using Monovisc. Furthermore, the options are limited. The patient has tried and failed other treatments, including physical therapy and platelet rich plasma injections. Therefore, the requested Monovisc injection in the left knee is medically necessary for the treatment of the patients medical condition.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: Overturned

A 23-year-old female enrollee has requested for residential treatment services for treatment of her anorexia. Findings:  The physician reviewer found that there is more than adequate evidence that extended residential treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested the Caris study for her diagnosis with stage IV colon cancer. Findings: Two physician reviewers found that the requested testing is not likely to be more efficacious than other modalities for evaluating this patient.  She has progressive metastatic colon cancer.  The Caris assay tests for the presence of multiple molecular markers which are believed to be of relevance to the pathogenesis of colon cancer and in the prediction of response to various chemotherapeutic agents.  However, there is insufficient evidence supporting the requested testing in this clinical setting.  Currently, the superior efficacy of the requested testing for predicting response to drugs has not been established by the current medical evidence.  In sum, the requested Caris study is not likely to be more beneficial than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL every four weeks. Current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has severe fistulizing and stricturing Crohn's disease status post multiple surgeries has had disease symptoms. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, the records reported  a low Stelara level of 3.3 ug/mL. Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL every four weeks is medically necessary for the treatment of this patient.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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/2 mL pen injector capsule for treatment of his short stature. Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The requested medication is not medically necessary for treatment of the patients medical condition. Based on the patients growth curve, he has reached mid parental height which appears to be 67 inches, + or -4 inches. The patient is now already 67.5 inches, and growth hormone supplementation is not medically indicated as he has reached his genetic potential. In addition, there is a lack of data provided of his height velocity prior to age 14. Accordingly, it is not possible to make a clinical determination as to whether he had normal height velocity or less than normal height velocity prior to age 14. 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 sub-specialty 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: Overturned

A 37-year-old female enrollee requested Acthar gel for medical treatment of the enrollees multiple sclerosis.  Findings:  The physician reviewer found that this patient has documented significant side effects with intravenous Solu-Medrol. Subsequently the patient tried Acthar gel and had a better response and fewer side effects. She also has intravenous access problems per her treating physician and Acthar is given intramuscular, so intravenous access is not an issue. Acthar gel is U.S. Food and Drug Administration (FDA) approved for treatment of multiple sclerosis exacerbations. It has previously been shown to be as effective as intravenous Solu-Medrol. While intravenous Solu-Medrol is the standard of care, Acthar gel is an option for those patients with no intravenous access, poor response to intravenous Solu-Medrol, and significant tolerability issues with Solu-Medrol. Given this patients documented intolerance to intravenous steroids and the documented response to Acthar Gel previously, Acthar gel is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for custom orthotic shoe inserts. The records provided for review do not support the medical necessity of a replacement pair of custom orthotic shoe inserts for this patient. The patient states that she needs a new pair of custom orthotics. However, the provider does not report whether the patient is currently wearing her worn out orthotics, or whether the orthotics need to be replaced. In addition, there is no physical examination of the patients foot structure to support an indication for orthotics. There is no evidence of palpable pain and or edema to either foot. The patient states that she requires orthotics because she underwent surgical correction of hammertoes and bunions in the past. Surgical correction should have corrected her hammertoes and bunions. The two most recent progress notes advise that the does not have foot pain, only right hallux toenail pain. All told, the requested custom orthotic shoe inserts are not medically necessary for 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 podiatry 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 cervical/thoracic facet joint block injection. In this case, the patient has pain complaints that are noted to be 8/10 in severity in the cervical spine. The patients pain complaints are corroborated by physical examination and imaging studies which demonstrate reduced cervical range of motion, facet tenderness and spondylosis. Further, the patient has failed to progress with adequate conservative measures including formal physical therapy, anti-inflammatory medications and opioid therapy. In a 2016 publication, found that the available evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. Given this support, the requested cervical/thoracic facet joint block injection is medically necessary for treatment of this patients medical condition. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy for treatment of the enrollee, who has a chronic non-healing wound.Findings:  The physician reviewer found that this patient has a chronic non-healing diabetic foot ulcer with complicating refractory osteomyelitis. The wound is classified as a Wagner stage 3 diabetic ulcer. The patient has been advised to proceed to the hospital for admission and amputation by his provider, but he has declined this treatment. His treatment has included local wound care, total contact cast, ongoing empiric antibiotics and at least 60 sessions of hyperbaric oxygen therapy. Hyperbaric oxygen therapy may be associated with improved healing as a component of diabetic ulcer management, but the indications for hyperbaric oxygen in the treatment of non-healing diabetic foot ulcers remain uncertain. The cornerstone of diabetic foot wound care includes adequate debridement, proper local wound care (debridement and dressings), redistribution of pressure on the ulcer by mechanical offloading, and control of infection and ischemia, regardless of stage and depth. There is a lack of randomized clinical trials evaluating the effects of hyperbaric oxygen on chronic, refractory osteomyelitis. This patient continues to have underlying infection that has been refractory to treatment. There has not been significant wound healing despite the previous 60 sessions of hyperbaric oxygen. There is a lack of support for the requested services in this clinical setting. All told, the requested hyperbaric oxygen therapy is not medically necessary for the treatment of this patient. 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 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 68-year-old female enrollee has requested hyaluronan (Supartz) injections for treatment of her arthritis. Findings:  Two physician reviewers found that viscosupplementation has been shown to be beneficial in the treatment of osteoarthritis of the knee.  However, its use has not been approved for the shoulder. Although some studies have shown benefit for viscosupplementation involving the shoulder, overall, there are insufficient randomized controlled trials demonstrating the superiority of viscosupplementation over standard therapy for the treatment of osteoarthritis of the glenohumeral joint.  Thus, the requested hyaluronan (Supartz) injections are not likely to be more beneficial than other available treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested authorization and coverage for Hizentra, 30 grams per month, divided into weekly doses for treatment of the enrollees immunodeficiency.  Findings:  The physician reviewer found that review of the submitted clinical information does not demonstrate the patient meets accepted clinical indications for Hizentra (immune globulin) at this time. The patients specific immunoglobulin levels showed a two to four fold increase post vaccination and his IgG levels appear to be within the normal range. In the absence of evidence of abnormal IgG levels, treatment with immune globulin is not supported. If future pneumococcal antibody titers demonstrate that the patients titers are not maintained, then the request for Hizentra should be reconsidered. Based upon the evidence provided, it is unlikely that Hizentra would be of any benefit at this time. Therefore, the Health Plans denial was appropriate in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an outpatient sleep study for the evaluation of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has had a diagnosis of sleep apnea.  The next step in his work-up is a CPAP titration study at a certified sleep medicine facility.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested outpatient sleep study is medically indicated for the treatment of this patient.   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 overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested robotic laparoscopy for medical treatment of her endometriosis.   Findings:  The physician reviewer found that when analyzed prospectively on a cohort basis, robotics has not been demonstrated to provide improved benefits in terms of post-operative pain, length of stay, and complications (Wright, et al). In addition, Liu and colleagues concluded that, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. For providers who are not adept at standard laparoscopy, robotic surgery may help provide minimally invasive surgery to their patients (Kho). All told, the use of robotic assistance for this patients hysteroscopy is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nucynta ER 200 mg tablets. Findings:  The physician reviewer found that the medical records document that this patient has a neuropathic pain condition. In addition, the provider reports that the patient has failed treatment including at least two opioids as well as one anticonvulsant. The patients pain is reportedly under good control with the Nucynta. Nucynta has demonstrated efficacy as published in the peer-reviewed medical literature as an option for neuropathic pain syndromes. Studies noted that in a blinded randomized controlled study, Nucynta had a minimal impact on bowel function (non-inferior to oxycodone/naloxone PR) and was associated with significantly lower incidences of constipation and vomiting and significant improvements in quality-of-life measure. Studies also reported that Nucynta showed benefit for treatment of neuropathic pain including diabetic peripheral neuropathy pain. Studies found that Nucynta had a positive role in the treatment of neuropathy. Since this patient has failed other agents but has demonstrated benefit previously with the Nucynta, the requested Nucynta ER 200 mg tablets are supported as 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 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested radioembolization with selective internal radiation therapy (SIRT) with yttrium-90 TheraSpheres for the treatment of his pancreatic cancer with liver metastasis. Findings:  Two physician reviewers found that SIRT with yttrium-90 TheraSpheres has been approved by the U.S. Food and Drug Administration (FDA) for treatment of hepatocellular cancer and has been utilized  with  safety and efficacy for this disease. While it is well-established that SIRT is useful for primary liver tumors, this case involves a patient with metastatic disease to the liver. There is no published literature supporting the use of SIRT in the management of patients with metastatic pancreatic cancer. As indicated by the patients provider, the primary pancreatic tumor site was unresectable so the patient was treated with chemotherapy with some response. The submitted evidence does not demonstrate that this patient has exhausted all systemic treatment. The requested therapy will treat disease in the liver only, and as such, is not likely to result in superior benefit over systemic therapy such as chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient has shown moderate to severe withdrawal symptoms per CIWA scoring. The patient does not have any reported biomedical conditions, but does have post-traumatic stress disorder (PTSD) and major depressive disorder (MDD). The patient is willing to change, yet he continues to exhibit mood swings and anger, without a high level of accountability. He shows self-sabotaging behaviors, which suggest that he is not yet able for meaningful change. The patients anxiety and mood symptoms have been pervasive in his life and are likely to persist placing him at high risk for relapse with self-medication. His partial compliance with medication will leave his symptoms partially treated, further putting him at risk for relapse. The patients recovery environment is supportive, but he has been unable to cope independently in an environment with minimal support. The patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level III treatment, similar to what patient has received at the RTC. Given the severity of the patients illness, the RTC services were and are medically necessary for treatment of this patient.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 Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.