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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for weekly allergy shots for treatment of the enrollee who has sensitivity to numerous allergens. Findings:  The physician reviewer found that Subcutaneous allergen immunotherapy (AIT) is a treatment for allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity that induces immune modulation by administration of gradually escalating doses of allergen. Conventional allergen immunotherapy schedules involve a build up phase and a maintenance phase, at which time the maintenance dose is reached.  The maintenance dose, or effective dose, is that which is believed to provide therapeutic efficacy without significant adverse local or systemic reactions.  If clinical improvement is not apparent after one year of maintenance therapy, possible reasons for lack of efficacy should be evaluated. If none are found, discontinuation of immunotherapy should be considered.Weekly maintenance dosing is a nonconventional schedule for allergen immunotherapy.  There is unclear evaluation for other potential factors for nonresponse in this patients case noted above. It is unclear from the documentation exactly how long the patient continued on monthly dosing prior to discontinuation. Data is lacking regarding the need and effectiveness for more frequent maintenance dosing. There is not a clear rationale provided for the nonconventional and more frequent dosing in this patients case. Therefore, weekly allergy shots has not been demonstrated as medically necessary for the treatment of this patients medical condition. Final Result: The reviewer has determined that the requested medication frequency 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 allergy and immunology 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 64-year-old female enrollee has requested Enbrel for the treatment of her rheumatoid arthritis and leukopenia. Findings:  The physician reviewer found that many rheumatologists who have a patient who has a relative contraindication to the use of methotrexate (such as mild leukopenia, or pulmonary disease) will use Enbrel alone because of the patients other risk factors for development of erosive, deforming arthritis. This patient has prognostic indications that suggest she will have aggressive RA, Enbrel is appropriate and should be used as soon as possible.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested coverage for a lesser metatarsal osteotomy for treatment of her hallux limitus/rigidus.  Findings:  The physician reviewer found that based on review of the available records, the patients history demonstrates multiple surgeries involving the 1st metatarsophalangeal joint (MPJ) of the right foot. Subsequent surgeries resulted in increased pressure and pain beneath the 2nd metatarsal of the right foot. Although the records indicate the patient has undergone physical therapy and steroid injections, it is unclear whether other conservative measures have been explored concerning the abnormal pressure on the 2nd metatarsal head. Additional therapies include non-steroidal anti-inflammatory drugs (NSAIDs), alternate shoe gear, and accommodative padding orthotics. In addition, there are no x-rays or imaging reports demonstrating the pathology at the 2nd metatarsophalangeal to establish the correct diagnosis and surgical plan. All told, the clinical records do not support the requested surgical procedure as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for FoundationOne gene testing services for treatment of the enrollees breast cancer. Findings:  The physician reviewer found that molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful.  However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial to the patient. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Some recent studies have expressed serious reservations about this approach in general. Therefore, the FoundationOne gene testing provided on 10/26/16 was not likely to have been more effective than other methods available for the evaluation of this patients medical condition.Final Result: The reviewers determined that the the services at issue were not likely to have been more beneficial for evaluation 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

A 54-year-old female enrollee has requested for Treximet for treatment of her migraine. Findings:  The physician reviewer found that the literature indicates that the pharmacokinetics of sumatriptan and naproxen in Treximet are not identical to that of the individual components. There is also literature support for clinical superiority for Treximet over its components, with lesser headache recurrence rates noted.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for placement on the liver transplant list. The American Association for the Study of Liver Diseases (AASLD) and American Society of Transplantation (AST) guidelines for evaluation for liver transplantation specify that alcohol abstinence for six months is recommended, and positive testing for alcohol is usually followed by delisting. However, this recommendation is not supported by adequate data regarding long-term graft and patient survival or recidivism rates. Ethyl glucuronide testing can be positive for up to 80 hours after consumption of small amounts of alcohol. Thus, exposure to ethanol-containing medications can result in a false positive test. The patient reported she took NyQuil for a cold prior to the positive test. NyQuil contains 10% alcohol. Based on the provided information, consumption of NyQuil close to testing may yield a false positive result on the ethyl glucuronide testing. The patients prior testing has been negative. One positive result in the setting of several negative tests suggest a false positive result due to NyQuil use. In this case, placement on the liver transplant list is appropriate for this patient who has decompensated cirrhosis of a hepatic allograft. Therefore, the requested placement on the liver transplant list is supported by guidelines and current medical literature.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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Dupixent.There is evidence to support Dupixent for treatment of dyshidrotic eczema. Waldman and colleagues conclude, Dupilumab is a generally well tolerated and frequently effective treatment for dyshidrotic eczema. Other treatments of proven value for dyshidrosis include phototherapy of various forms, oral steroids, and oral immunosuppressants, but there is a lack of studies to show superiority of a particular treatment. Moreover, there are no agreed upon treatment guidelines for dyshidrotic eczema. In this case, the patients condition is consistent with dyshidrotic eczema. The clinical images and documentation do not support a diagnosis of atopic dermatitis, which does not present as an acral-limited bullous eruption. The medical literature supports the use of Dupixent for treatment of the patients condition. Therefore, Dupixent is medically necessary for treatment of the 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with left knee pain and left knee osteoarthritis. The patient reported left knee pain. She has failed treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and arthroscopic left knee surgery. The provider noted the patient had a prior adverse reaction to a cortisone injection. The patient has requested reimbursement for four Supartz injections that were received. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  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. Researchers 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 were limited. The patient had an anaphylactic reaction to cortisone in the past and had tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the services at issue. Therefore, four Supartz injections that were received were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 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:  The enrollee is requesting authorization and coverage for Home Health Transitional Care Management (TCM), including weekly home nurse visits. The enrollee has a history of type II diabetes, recurrent seizures, and migraines. Enrollee was hospitalized for abdominal pain and was treated with intravenous (IV) antibiotics for methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. At the time of hospital discharge, the enrollee completed five days of intravenous antibiotics, and did not require peripherally inserted central catheter (PICC) line-placement for continuous outpatient intravenous antibiotics. On an outpatient follow-up visit, notes indicate the enrollee was feeling great and denied symptoms of infection since hospital discharge. Despite her stable condition and ability to follow-up as an outpatient, authorization for Transitional Care Management was requested due to the enrollees hospital admission for bacteremia. Literature support for Transitional Care Management is focused on enrollees who are at high-risk for re-hospitalization, which include enrollees with multiple comorbidities; polypharmacy (use of multiple drugs); depression; functional impairment; low self-health rating; history of non-adherence; an inadequate support system; or are greater than 65 years old. Although this enrollee has poorly controlled diabetes, there is no medical indication of the enrollees non-adherence or non-compliance to medication or outpatient care. Rather, the medical records show outpatient follow up for her diabetes management, and the hemoglobin (Hg) A1c is an improvement (reduction) from previously elevated HgA1c. The request for Transitional Care Management for bacteremia is not supported by the literature or the enrollees clinical presentation. The enrollee completed course of intravenous antibiotics while in the hospital, and is asymptomatic and able to follow-up with outpatient provider without difficulty.  While she reports seizures and needing assistance getting out of bed sometimes, this is unrelated to enrollees recent admission for bacteremia, and thus, does not support the request for Transitional Care Management. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and infectious diseases 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

A female enrollee requested Xenical for medical treatment of her morbid obesity.   Findings:  The physician reviewer found that according to American Association of Clinical Endocrinologists and American College of Endocrinology guidelines, pharmacologic therapy is indicated in addition to dietary and exercise therapy in patients with BMI greater than 30. This patient has a BMI of 40.62 and is an appropriate candidate for pharmacologic therapy such as Xenical in addition to dietary and lifestyle changes. Thus, the requested Xenical is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested residential substance abuse treatment for treatment of his substance abuse.  Findings:  The physician reviewer found that the records reviewed indicate the patient demonstrated a lack of motivation for recovery despite the fact that he had been in the residential treatment substance abuse program for two weeks. He relapsed immediately after discharge despite an identified treatment plan. The patients pervasive substance use indicates a lack of motivation to engage in treatment which is a necessary requirement for substance abuse treatment at a residential level of care. Further, American Psychiatry Association and American Society of Addiction Medicine guidelines indicate that patients should be managed in the least intensive setting that is likely to be safe and effective. Given this patients lack of motivation for recovery, continued treatment at a residential level of care was not likely to be more effective than a sober living situation with adjunctive partial hospitalization or intensive outpatient services. All told, the submitted documentation does not establish the medical necessity for residential substance abuse treatment services provided from the dates in question and does not establish the medical indication for completion of a 30-day residential substance abuse rehabilitation program
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 54-year-old male enrollee has requested continued skilled nursing services for the treatment of his complex cervical spine fracture with quadriparesis. Findings:  The physician reviewer found that the patient was not in pain and was not receiving treatment that required the skills of a nurse, such as wound management with dressing changes, frequent nebulizer treatments or intense blood sugar monitoring. The patient was turned every two hours, but this does not require a skilled nurse. He was not getting intravenous medications which would have required a skilled nurse. There did not seem to be an increased likelihood of an adverse event that required the daily monitoring from a nurse or a physician. In regards to rehabilitation services, both occupational and physical therapy services had been discontinued. Finally, there was an order from the physician to discharge the patient demonstrating the stability of the patient and the ability to manage him without continual physician or nursing care.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested outpatient individual therapy for treatment of her major depressive disorder and cognitive disorder. Findings:  The physician reviewer found that this patient has both severe medical problems as well as mental health needs. She is at significant risk for life threatening decomposition such as depressive episode and seizures. Given the patients continued need for supportive mental health services, individual therapy is a minimal therapeutic intervention to sustain the patients positive health beneficial behaviors and mental state.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral procedure (CPT code 19340) and bilateral procedure (CPT code 19316) in addition to the already approved CPT code 19371. Findings:  The physician reviewer found that the patient has a symptomatic, painful capsular contracture of both breast implants. As the initial surgery was deemed medically necessary from the documentation provided, reasonable surgical intervention is medically necessary as well.  Standard treatment for significant capsular contracture is implant replacement (or removal) and capsulectomy. Thus, the request for bilateral procedure (CPT code 19340) is considered medically necessary. However, the requested mastopexy, bilateral procedure (CPT code 19316) is not medically necessary and reconstructive in nature for treatment of the patients medical condition. The medical documentation does not support that a functional deficit is related to any skin to skin overlap that would be corrected with this procedure. There is a lack of sufficient documentation supporting bilateral procedure (CPT code 19316) as medically necessary or reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested a replacement infusion pump for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested replacement infusion pump.  In general, opioid intrathecal pump infusion is not recommended for chronic pain associated with posterior lumbar spine fusion.  Per the clinical records, this patient may benefit more from removal of the intrathecal pump and weaning off opioids, as her symptoms of increased pain may be the result of opioid-induced hyperalgesia.  Angst and Clark presented a systematic review on opioid-induced hyperalgesia.  The authors observed that very high doses of certain opioids can produce allodynia and possibly hyperaglesia.  Per the authors, the hyperalgesic state can be aggravated when the dose of the opioid agonist is increased.  The current medical evidence does not support the requested equipment in this clinical setting.  All told, the requested replacement infusion pump is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested  for bilateral reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the patient has symptoms that are typical for symptomatic macromastia, and all attempts at conservative therapy have failed. This is not surprising, as an outcome study by Collins and others has shown that conservative therapy is generally not effective for the musculoskeletal symptoms associated with macromastia. The Schnur table is a well-accepted guideline for differentiating medically necessary breast reduction from cosmetic mastopexy. Schnur considers reductions below the 5th percentile cosmetic and reductions above the 22nd percentile medically motivated. For reductions falling between the 5th and 22nd percentiles, Schnur essentially states that if the patient is symptomatic and conservative measures have failed, the breast reduction should be covered. In this instance, the planned reduction may be below 22nd percentile weight of 260 grams. However, the record documents the patient has seen two physicians and has tried chiropractic care, analgesics, acupuncture and special bras without symptom relief. According to Schnur, the proposed breast reduction is a functional one and is not cosmetic.