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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vumerity.There is sufficient support for the requested medication in this clinical setting. Adherence to a disease-modifying therapy (DMT) may be affected by medication adverse effects. In 2019, the American Academy of Neurology (AAN) issued practice guideline recommendations for DMTs for adults with multiple sclerosis (MS). Clinicians should offer DMTs to people with relapsing forms of MS.  Clinicians should inquire about medication adverse effects with people with MS who are taking a DMT and attempt to manage these adverse effects. Clinicians should discuss a medication switch for patients with MS for whom these adverse effects negatively influence adherence.According to the U.S. Food and Drug Administration (FDA), Tecfidera (dimethyl fumarate) is indicated for the treatment of relapsing forms of MS. Additionally, the FDA has approved Vumerity (diroximel fumarate) as a DMT for people with relapsing forms of MS, including clinically isolated syndrome (an initial neurological episode), relapsing-remitting MS, and active secondary progressive MS. In a study by Naismith and colleagues, diroximel fumarate demonstrated an improved gastrointestinal tolerability profile compared with dimethyl fumarate, with less severe gastrointestinal events and fewer days of self-assessed gastrointestinal symptoms, fewer gastrointestinal adverse events, and lower discontinuation rates because of gastrointestinal adverse events.In this case, the patient has multiple sclerosis and is experiencing adverse effects with his current DMT. Based on the AAN practice guidelines above, switching to another DMT is indicated. The references above indicate that Vumerity is similar to Tecfidera but has a distinct chemical structure that has been shown to have fewer reported gastrointestinal side effects than Tecfidera. Therefore, Vumerity is medically necessary for the 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Researchers found that physical rehabilitation for long-term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. The documentation provided for review reports that this patient is currently in a SNF, but is receiving custodial care. There is no reported indication for continuation of rehabilitation level of care with SNF services. The provider noted that the patient is planned to receive PT and OT, but these services can be provided on an outpatient basis. For these reasons, the requested SNF level of care is not medically necessary for 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 with subspecialty certification in nephrology 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 20-year-old male enrollee requested myoelectric custom molded elbow wrist hand orthosis for treatment of his right upper extremity weakness and facioscapulohumeral muscular dystrophy (FSHD). Findings:  The physician reviewer found that the requested myoelectric custom molded elbow wrist hand orthosis is not medically necessary for treatment of the patients medical condition. There is minimal support in the medical literature for the use of the requested device to ameliorate the patients functional deficits. Trials focus on the use of myoelectric devices as adjuncts to exercise therapy, not as devices to directly augment function (Song et al; Stein et al). Cavallaro and colleagues have shown that myoprocessors are a viable control option for an orthosis. The peer-reviewed literature fails to show that the requested device has been used to improve the function of individuals. Given the lack of support in the peer-reviewed literature, the requested device is not medically necessary. For the reasons provided, the requested myoelectric custom molded elbow wrist hand orthosis is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara, 90 mg every four weeks and reloading dose of Stelara 390 mg infusion The Health Plan has denied this request indicating that the requested medication, reloading dose and increase in maintenance dose are not medically necessary for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that current medical literature supports dose escalation of Stelara in this case, but not a reloading infusion. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for 1 year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, both of which the enrollee has failed.  A 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.  Additionally, in this case, alternative therapies are limited.  However, there is a lack of support in the literature for a reloading infusion.  For these reasons, the request for Stelara 90 mg subcutaneously every four weeks is supported as medically necessary for the treatment of this patients Crohns disease but the reloading dose is not medically necessary. Final Result: The reviewer determined that a portion of the requested medication, reloading dose and increase in maintenance dose is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has reimbursement for Supartz injections provided by Torrance Memorial Physicians and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee.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 conclusive 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 patients options were limited, as she did not respond to other conservative treatment, including medication, bracing, and activity modification. Therefore, Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee were and are medically necessary for the 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 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: An enrollee has requested authorization and coverage for Tymlos 80 mcg injection or Forteo 20 mcg injection. The patient has severe osteoporosis of the spine that has caused multiple compression fractures requiring multiple vertebroplasties and back surgery. Unfortunately, because of the compression fractures, the patient is in pain. Just by the fact that she has had compression fractures, the patient's risk for additional compression fractures is very high. Miller notes, `Whether symptomatic or asymptomatic, they (vertebral fractures) both represent a high risk for not only vertebral but also nonvertebral fractures in untreated populations. This high risk of future fracture after a VCF (vertebral compression fracture) is independent of the T-score because bone strength is a combination of bone mineral density and bone quality. VCFs are the single greatest risk for future fractures at all other skeletal sites in untreated populations, including hip fractures. It is therefore important for a patient with compression fracture(s) to receive the most efficient therapy in the correct sequence to optimize healing and decrease the risk of additional fractures. Additional compression fractures of the spine or a hip fracture will significantly add to the already sick patient with multiple aliments. The Health Plan is requiring the use of an antiresorptive agent, denosumab (Prolia), prior to the approval of an anabolic agent, Tymlos or Forteo. Cosman and colleagues have documented that the treatment sequence matters and the use of an anabolic agent such as teriparatide and now the abaloparatide in the same family, followed by an antiresorptive agent will be the most efficient way to treat this patient. Iwata and colleagues indicate teriparatide has been shown to optimize healing of vertebral fractures. Miller and colleagues note a recent study has shown that abaloparatide had greater response rate than teriparatide in increasing bone mineral density. This patient needs Tymlos or Forteo urgently to continue her treatment with this anabolic agent given her history of severe osteoporosis. Once the treatment cycle with Tymlos or Forteo is completed, she should be transitioned to an antiresorptive agent to prevent loss of the gains in strength and bone density. Treatment with Tymlos or Forteo is medically necessary for this patient at this time, and must be completed prior to the antiresorptive therapy. 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 sub-specialty certification in endocrinology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for abatacept (Orencia) infusions to be administered at a pediatric-tailored infusion center associated with a hospital. Current medical literature does not provide specific guidance regarding the administration of IV abatacept at a pediatric outpatient infusion center affiliated with a hospital versus at home, at a doctors office, or at an outpatient infusion center that is not affiliated with the patients primary hospital. Researchers noted that in the treatment of JIA, compared to other biologics, abatacept showed a lower rate of serious adverse events and the lowest rate of infection. In this case, the provider noted concerns regarding the patients MCTD/SLE overlap syndrome creating difficulty in establishing proper IV access and of possible adverse reactions to the infusion. However, infusion therapy notes indicated the patient tolerated IV infusion without complications or reactions. Therefore, abatacept (Orencia) infusions to be administered at a pediatric-tailored infusion center associated with a hospital are 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 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 female enrollee requested Oasis graft product for medical treatment of her third-degree burns.  Findings:  Three physician reviewers found that this patient underwent tangential excision with temporary wound coverage with homograft and xenograft to some sites before coverage with autograft.  There is a lack of support for the use of Oasis graft product in this clinical setting.  The Oasis product is not indicated for patients with third-degree burns.  All told, the use of Oasis graft procedure was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested termination of pregnancy for treatment of her medical condition. Findings:  The physician reviewer found that the patient had two maternal fetal medicine consultations suggestive of the diagnosis of craniosynostosis. The differential diagnosis was discussed, and prenatal molecular testing was offered for further diagnostic evaluation. The syndromes associated with craniosynostosis and FGFR mutations include Apert syndrome, Crouzon, Pfeiffer, Jackson-Weiss and Adelaide type.  As noted by Renier and colleagues, although these syndromes can be associated with possible mental retardation and possible developmental delay and can require several significant surgical procedures, the long-term prognosis can be very good and is associated with long-term survival. Given the specific nature of the sonographic findings and consistency between the two maternal fetal centers, it is unlikely that the differential diagnosis would have also included other syndromes that are associated with a fetus that would be more likely nonviable. In this patients case, her life was not in jeopardy based upon the sonogram findings. Additionally, had the fetus been carried to full-term and delivered, her life would not have been in any greater jeopardy than the normal risks associated with full-term pregnancy. Furthermore, termination of pregnancy was not medically necessary due to fetal nonviability.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 41-year-old female with the diagnoses of severe persistent asthma, gastroesophageal reflux disease, severe eczema, multiple allergies confirmed by skin tests, and osteoporosis. The patient is seeking authorization for the medication Xolair.According to the records provided, the patient has had four emergency room/urgent care visits for asthma exacerbations over the last six months. The patient has been on multiple medications to help control her asthma including Foradil, Azmacort, Accolate, Singulair, albuterol MDI, albuterol nebulizer, and oral corticosteroids. Despite these medications, the patient has required multiple emergency room/urgent care as well as frequent office visits.According to the patients pulmonologist, the patient does not tolerate inhaled corticosteroids because of dysphonia. A spirometry performed in October 2003 demonstrated FEV1 114% of predicted normal FVL. This was attributed to the fact that the patient was on oral corticosteroids. Notes from the patients allergist confirm the patient has severe eczema and multiple allergies. The patient also has a history of anaphylaxis. In addition, the patients rheumatologist confirms the patient has glucocorticoid-induced osteoporosis stemming from her asthma treatment.The purpose of this review is to determine whether Xolair is medically necessary for treatment of the patients asthma.It appears the Health Plan has denied authorization for Xolair on the basis that the patient was not consistent with her use of leukotriene and that her FEV1 was greater than 80%. Based upon the information provided, the patient was on Accolate and Singulair with no significant benefit. The patient has had to be on chronic oral prednisone in order to control her asthma. The fact that the patient had a normal spirometry does not exclude asthma.According to the National Asthma Education and Prevention Center guidelines, based upon the patients frequent utilization of the emergency room and need for oral prednisone, the patient has poorly controlled asthma. The patient already suffers from steroid-induced osteoporosis and should discontinue use of oral steroids as soon as possible. In addition, because the patient has GERD the use of theophylline is relatively contraindicated. Furthermore, her atopy and severe asthma make her a good candidate for Xolair.Based upon the information set forth above, I have determined 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stem cell therapy. Cerebral palsy is a condition that results in motor disability. It can be caused by perinatal hypoxic insults, genetic conditions and trauma. Stem cells are undifferentiated cells that are speculated to have regenerative abilities. Stem cells have been shown in vitro to have the capacity to induce angiogenesis and differentiate into different types of cells, including cells of the nervous system. While theoretically stems cells may contribute to improvement in a patients neurological status, there is a paucity of quality data to support this treatment modality as effective in this patients case. The current medical evidence does not support the requested services in this clinical setting. Therefore, the requested stem cell 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone HCL 10 mg tablets. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. In addition, there is no mention that behavior therapy has been completed despite much research to support its use. Moreover, not all non-opioid medications classes have been optimized or tried. All told, the requested methadone HCL 10 mg tablets is not supported as medically necessary for treatment of this patients chronic pain. 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 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: Overturned

A 47-year-old female has requested coverage for past repetitive transcranial magnetic stimulation  for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted medical records demonstrate the medical necessity of the services at issue.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the treatment of individuals with depression.  In this particular case, the patient was enduring an acute major depressive episode that was causing significant morbidity and functional impairment.  She had pursued other standard therapies used to treat her depression.  The current medical evidence supports the services at issue in this patients case.  Based upon the medical records and peer-reviewed literature, transcranial magnetic stimulation was indicated to treat this patients depressive symptoms.