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

The enrollee is requesting authorization and coverage for Stelara, 90 mg every four (4) weeks. This enrollee has psoriatic arthritis and Crohns disease. She began treatment with Stelara, 90 milligram injections every eight weeks. The enrollees rheumatologist reports that, due to rapid metabolism of the drug, dose escalation for biologics is commonly required for medically unresponsive, severe Crohns disease. There is a body of literature addressing an administration frequency of every four weeks. Studies report the benefit of this dosing schedule; without increased toxicity. It is a matter of clinician judgment as to whether it is riskier to utilize an every-four-week regimen of a medication the enrollee has used and tolerated, or to change to another type of treatment. Her options are limited. Any change to her medication introduces the risk of either inferior results or toxicity.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested knee surgery for treatment of the enrollees torn meniscus.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this clinical setting.  Based upon the medical records, there is a likelihood of recurrent tear of the meniscus.  Recurrent tears of the meniscus can be present after arthroscopic meniscal surgeries due to disruption of the internal collagen structure of the meniscus.  In this case, direct visualization and probing is indicated to accurately assess this patient.  Additionally, there is a possibility of a post-traumatic inflammatory chondrolysis which will thin and disrupt the cartilage surfaces.  In this patients case, a third diagnostic and therapeutic arthroscopic surgery is medically necessary.  All told, the requested knee surgery is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old male enrollee has requested the X-Stop interspinous implant procedure for the treatment of his lumbar spinal stenosis and lumbar radiculopathy. Findings:  Two physician reviewers found that the X-Stop device is designed to distract the posterior elements of the stenotic segment and place it in flexion to treat neurogenic claudication.  These devices continue to be evaluated in clinical trials. Early results suggest a possible role in the management of degenerative disorders of the lumbar spine. In the study evaluating the device, the primary indications were age of at least 50 years, lower extremity pain (with or without back pain) that was relieved with flexion (forward bending) and ability to walk at least 50 feet. However, FDA documents released before a public hearing on the product raised concerns that the X-Stop's effectiveness decreases over time, as studies found that about 15 percent of patients who had the implant reported symptoms returning. It appears that the X-Stop is effective for about one year and then begins to decline, according to the FDA. This patient does not have neurogenic claudication that is relieved by forward flexion.  He has multilevel stenosis.  This patient would have been most appropriately treated by nonoperative treatment or decompressive laminectomy and possible fusion. There is a lack of support from available literature demonstrating that the X-Stop device was likely to be more efficacious than any other standard therapy for this patient, and it is more likely associated with a high rate of failure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 units subcutaneously twice a week. The U.S. Food and Drug Administration approves the use of Acthar Gel for rheumatic disorders and diseases, such as systemic lupus erythematosus (SLE) flares. In a study of the use of Acthar Gel in SLE treatment, Li and colleagues concluded that their study suggests a role for Acthar Gel as an alternative to corticosteroids in the treatment of SLE. Acthar Gel appears to be safe and well-tolerated after six months of treatment, with a significant reduction in disease activity. In a study of 44 patients with nephrotic syndrome (NS) who failed to respond to standard therapy, Studies found that, Acthar Gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this case, the patient has failed standard therapy and is experiencing complications of chronic corticosteroid use. The records demonstrate that the patients care has been complicated by recurrent infections, including a significant infection resulting in a four-month hospital stay, and bilateral avascular necrosis of the hips. Therefore, HP Acthar Gel 80 units subcutaneously twice a week is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male has requested coverage for Bioness H200 Hand Rehabilitation System (for left hand) and the necessary supplies for its operation for treatment of his status post large right middle cerebral artery stroke secondary to right carotid artery dissection.  Findings:  Two physician reviewers found that the submitted documentation indicates that the patient has had stiffness, swelling and pain following the stroke.  In this patients case, the superior efficacy of the requested equipment has not been demonstrated.   There is no record of use of anti-spasticity treatments, such as baclofen or Botox.  Botox is an established treatment for the management of upper limb spasticity.  Tarkka and colleagues conducted a study of adult stroke survivors.  The authors noted that functional exercise augmented with individualized electrical therapy may enhance neuroplasticity, observed as corticospinal facilitation along with moderate improvements in the voluntary motor control of the affected limb.  Constraint induced therapy has been shown to be beneficial in recovery from upper limb spastic hemiplegia. The current medical evidence does not demonstrate that functional electrical stimulation is superior over constraint induced therapy, Botox, or physical therapy measures.  Therefore, the requested Bioness H200 Hand Rehabilitation System (for left hand) and the necessary supplies for its operation are not likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synthroid 112 mcg for treatment of the enrollees hypothyroidism status post total thyroidectomy. Findings:  The physician reviewer found that The medication of choice in hypothyroidism is levothyroxine, which is very effective and well tolerated. There are numerous preparations of levothyroxine, including Synthroid, Levoxyl and Unithroid. However, there is a lack of clinical data demonstrating that there is a difference in safety or efficacy between the various brands. Given that this patients records do not document an adequate trial of the Health Plans formulary alternatives including Levoxyl, Levo-T, or Unithroid, the requested Synthroid 112 mcg is not supported as medically necessary for treatment of this patients hypothyroidism. 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 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

The patient has requested authorization and coverage for Synvisc injections in both knees. The patient has been diagnosed with osteoarthritis of both knees. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Synvisc injections in both knees 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) injection. Findings:  The physician reviewer found that current evidence based medical guidelines recommend a single platelet rich plasma (PRP) injection as a second line therapy for chronic lateral epicondylitis after first line treatment of physical therapy such as eccentric loading, stretching and strengthening exercises. Peer reviewed literature supports the use of PRP in recalcitrant lateral epicondylitis as providing clinically significant pain reduction and functional improvement. However, in this patients case, there is a lack of evidence to indicate that he has fully optimized conservative treatment. This patient presented with a six month history of right elbow pain. Symptoms were worse with playing golf. Clinical examination findings were consistent with the diagnosis of right lateral epicondylitis. The patient has tried some anti-inflammatory medications with some benefit. He was not able to avoid the aggravating activity because he is a golf instructor. The provider recommended a trial of elbow strapping, continued anti-inflammatory medications, home exercises, and referred the patient to occupational therapy. A PRP injection was recommended for the right elbow as a first line injection over corticosteroid injection. While there is current evidence based medical guideline and peer reviewed literature to support a single PRP injection in the treatment of recalcitrant lateral epicondylitis, this patient has not exhausted all the available conservative treatment options available. Therefore, the PRP injection is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are 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 & 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are 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 20-year-old female enrollee requested keloid removal for medical treatment of the enrollees keloid scar. Findings:  The physician reviewer found that based on review of the available records, removal of keloid via surgery is reconstructive in nature and medically necessary for treatment of this patients keloid. A keloid constitutes an abnormal structure of the body resulting from the disease of collagen metabolism in the wound site. In addition, removal of the keloid will create a normal appearance to the extent possible, and provide a more than minimal improvement and alleviate the psychological impact of the disease. While surgical excision is reconstructive in nature and medically necessary, surgery alone most likely will not be curative. The patient should be advised to consult a dermatologist experienced with treating keloids for comprehensive therapy. For these reasons, the requested removal of the keloid is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for Xifaxan 550 mg tablets (42 tablets for 14-day supply). Menees and Chey found that recent studies have demonstrated that an imbalance in gut bacterial communities, or dysbiosis, may be a contributor to the pathophysiology of irritable bowel syndrome (IBS). Ponziani and colleagues found that rifaximin was a safe antibiotic for gut microbiota modulation in patients with IBS, while Gatta and Scarpignato noted that rifaximin also seemed to be effective and safe for the treatment of small intestinal bacterial overgrowth (SIBO). In this case, the patient has documented overgrowth of certain bacteria and symptoms such as bloating that are associated with IBS. Xifaxan is effective in treating these symptoms, with few adverse events and is medically indicated for this patient. Therefore, Xifaxan 550 mg tablets (42 tablets for 14-day supply) 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Tecentriq 1200 mg provided on 7/23/21, 8/13/21, 9/24/21 and prospective authorization and coverage for Tecentriq 1200 mg every 21 days.The National Comprehensive Cancer Network guidelines for small cell lung cancer states that the standard of care for extensive stage small cell lung cancer is carboplatin, etoposide, and atezolizumab (Tecentriq), with Tecentriq continued as maintenance therapy. In this case, the patient has extensive stage small cell lung cancer which may have arisen out of his high-grade prostate cancer. The medical literature indicates that small cell cancer, regardless of origin, are treated like small cell lung cancers, which explains the patients normalized prostate-specific antigen (PSA) despite metastatic disease. Therefore, Tecentriq 1200 mg provided on 7/23/21, 8/13/21, 9/24/21 and forward for every 21 days was and is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was and 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 medical oncology 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 Orencia for treatment of her medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The provider feels that given the patients systemic lupus erythematosus features, anti-tumor necrosis factor agents would be contraindicated.  Orencia is requested as it may be used without methotrexate.  In this case, the provider would prefer to use it without methotrexate given an inability by the patient to tolerate methotrexate.  Orencia has been approved for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors.  This medication appears to be most effective in certain subsets of rheumatoid arthritis patients.  In this case, the patient is seronegative for rheumatoid factor.  The records fail to demonstrate any poor prognostic factors or radiographic evidence of joint erosions.  There is a lack of support for the requested medication in this clinical setting.  All told, Orencia is not medically indicated 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 with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a six-year-old male enrollee has requested for sensory integration occupational therapy for treatment of the enrollees behavioral problems. Findings:  Three physician reviewers found that sensory integration occupational therapy has been proposed for many years. To date, there is no scientific basis to support its use. It is not a medical therapy, but a psycho-educational one and is considered experimental. There is no evidence to support such therapy as beneficial for this patient. It is highly likely the patient will benefit from some type of one-to-one therapy and from assistance from his family and teachers; however, there is no medical indication for sensory integration occupational therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested  intensive outpatient therapy 2 to 3 times per week for treatment of the enrollees depression.  Findings:  The physician reviewer found that the according to American Academy of Child and Adolescent Psychiatry (AACAP) guidelines, treatment of psychiatric conditions should take place in the least restrictive environment possible. The requested level of care is a lower, less restrictive level of care than PHP. The patients records indicate that she is being cooperative with the requested therapist and is not presenting as a risk of harm to herself or others. The importance of a therapeutic bond between the patient and therapist should not be underestimated. If the patient did not feel comfortable with the level of care, it is highly unlikely that she would be able to resolve her issues and her time in treatment would most likely not be productive. Finally, the patient has family support to attend the intensive outpatient therapy sessions two to three times weekly. Since the records indicate that parental conflict and family dysfunction is a major contributor to the patients symptoms, it is essential that the patients treatment program allows for full participation of the involved family members. Therefore, the requested level of care is more appropriate than PHP and is medically necessary for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the platelet rich plasma injections provided on multiple dates. The Health Plan has denied this request as investigational for treatment of the enrollees large-cell lymphoma tumor of the abdomen. Findings:  Three physician reviewers found that the use of platelet rich plasma is not considered a standard of care for the treatment of lymphoma and is not supported by the National Comprehensive Cancer Network Guidelines. A search of the medical literature in numerous research sources failed to reveal any medical literature to support the use of platelet rich plasma for use in the treatment of lymphoma. There are standard methods by which to stage and treat diffuse large B-cell lymphoma. Advanced cases will require multi-agent chemotherapy with rituximab and CHOP, cyclophosphamide, doxorubicin, vincristine, and prednisone. Platelet rich plasma has no role in the treatment of lymphoma and has dubious indications. Therefore, the platelet rich plasma injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty in medical oncology and hematology 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.