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

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication H.P. Acthar gel for treatment of the enrollees systemic lupus and ankylosing spondylitis.  Findings: The physician reviewer found that a recent study evaluated H.P. Acthar gel in patients already on other immunosuppressive agents. The authors found that this study suggests a role for Acthar gel as an alternative to corticosteroids in the treatment of systemic lupus erythematosus. Acthar gel appears to be safe and well-tolerated after six months of treatment, with a significant reduction in disease activity (Li, et al). However, this study was a small case series with nine female patients who were on other immunosuppressive agents in addition to Acthar. Another study of 44 patients with systemic lupus erythematosus and nephrotic syndrome (NS) who failed to responds to standard therapy had a response with Acthar. The authors reported 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 (Madan, et al). In this case, the records demonstrate that the patient is responding to corticosteroids. There is no history of nephritis and there is a lack of guidelines or large randomized control studies demonstrating benefit of Acthar gel in patients with systemic lupus erythematosus. As such, the request for H.P. Acthar is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested emergency room services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with severe pain that persisted, awakened her from sleep, and was exacerbated by breathing. A prudent person would have been concerned for the possibility of serious medical illness as an etiology. The pain was consistent with pulmonary embolism, thoracic aortic dissection, kidney stone, spontaneous pneumothorax, and multiple other etiologies.  Any of these conditions could have put the patients life in immediate jeopardy and may have caused serious impairment to bodily functions. In sum, the patient was suffering from symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in causing serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided did meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services.  Credentials/Qualifications: The reviewer is board certified in emergency 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

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for Ruxience (rituximab-pvvr) infusions (700 mg infused weekly for 4 doses). Gilhus and Verschuuren describe myasthenia gravis as an autoimmune disease that is B-cell mediated, and is associated with antibodies directed against the acetylcholine receptor, muscle-specific kinase (MUSK), lipoprotein-related protein 4 (LRP4), or agrin in the postsynaptic membrane at the neuromuscular junction. Standard pharmacotherapy including acetylcholine esterase inhibitors, corticosteroids, and nonsteroidal immunosuppressive agents, including azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, and tacrolimus, and are usually effective in the treatment of myasthenia gravis. Treatment options are limited for refractory myasthenia gravis, and may include chronic intravenous immunoglobulin (IVIG) or plasma exchange, high-dose cyclophosphamide, rituximab, and eculizumab. As major effector cells in autoimmunity, targeted therapy of B-cells has emerged as a promising approach to treat autoimmune diseases. Rituximab is a monoclonal antibody against the B-cell membrane marker CD20. Choi and colleagues report that repeated low-dose rituximab treatment based on the assessment of circulating B-cell depletion could be a cost-effective therapeutic option for refractory myasthenia gravis. Regarding chronic immunotherapy for myasthenia gravis, Bird notes that rituximab may be used for the treatment of refractory myasthenia gravis. Narayanaswami and colleagues report that rituximab may be an option for patients with refractory myasthenia gravis that fail or do not tolerate other immunosuppressive agents. The optimal dose and dosing interval of rituximab for myasthenia gravis has not been established. A common initial dose is 375 mg/m2 weekly for four doses. Whether and when to repeat rituximab dosing in patients who respond to the initial course is generally guided by clinical symptoms and lymphocyte recovery. Ruetsch-Chelli and colleagues report that the percentage of memory B-cells in whole blood cells can accurately predict clinical relapse in myasthenia gravis patients treated with rituximab. In this case, the patient has autoimmune myasthenia gravis that has been refractory to standard therapy. The provider recommends treatment with rituximab based on increasing B-cell counts and for prevention of clinical relapse of the patients myasthenia gravis. Given that current medical literature supports the potential efficacy of rituximab in patients with refractory myasthenia gravis and that repeat treatment can be guided by circulating B-cells, the requested service is medically indicated. Therefore, Ruxience (rituximab-pvvr) infusions (700 mg infused weekly for 4 doses) is 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Remicade (infliximab) injections every eight weeks.Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohns disease, thiopurines are not recommended as primary monotherapy, and tumor necrosis factor (TNF) inhibitors such as Remicade are recommended. These recommendations are corroborated by the American Gastroenterological Association guidelines. For patients with moderate to severe Crohns disease, guidelines do not recommend alternative therapy, such as aminosalicylates, corticosteroids, and antibiotics, as long-term primary therapy as they are unlikely to prevent complications. American College of Gastroenterology guidelines also recommend Remicade as primary monotherapy for the induction of remission of Crohns disease. In this case, the patient is unlikely to respond to conventional alternatives, such as immunosuppressants, corticosteroids, and 5-aminosalicylate therapy. The patient has been on Remicade since 2005 and failed thiopurine therapy. The patient is at risk for Crohns disease complications such as fistula, stricture, hospitalization, and need for surgery if induction and maintenance of remission is not effective. Therefore, Remicade (Infliximab) injections every eight weeks are medically necessary for the treatment of the 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 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 patient has requested authorization and coverage for Praluent for treatment of the enrollees hypercholesterolemia and severe atherosclerotic cardiovascular disease. Findings:  The physician reviewer found that based on the records provided this patient presents with statin intolerance and increased coronary risk but no documented symptoms of coronary ischemia, ischemia on stress testing, or clinical coronary events. The patient has an elevated calcium score with up to 70% stenosis in the left anterior descending coronary artery. The coronary CT scan as reported does not accurately quantify stenosis likely due to the presence of significant calcium. In summary, the documentation provided does not confirm the presence of obstructive coronary disease. Praluent is a PCSK9 inhibitor that has been demonstrated to be safe and effective for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical obstructive atherosclerotic heart disease who require additional lowering of low density lipoprotein (LDL) cholesterol. This patient does not meet these criteria. PCSK9 inhibitors have not been studied in other patient populations. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this setting. 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 19-year-old female enrollee has requested Botox injections for treatment of her pain secondary to connective tissue disorder and migraine headaches. Findings:  Three physician reviewers found that this patient has been diagnosed with seizures and daily headache with migraine, with underlying diagnosis of vasculitis. Her records suggest failure on standard preventives including medication for seizure control and calcium blockers that were limited by side effects. The clinical literature regarding Botox proves it to be well tolerated, generally without systemic side-effects, and with adverse effects that are generally mild to at most moderate. Recent studies with large patient populations show definitive benefit in patients with chronic migraine in comparison to placebo. Also demonstrated is a marked improvement in patients treated with Botox over the course of study, even in those with ongoing medication overuse. Thus, there is adequate evidence that Botox is more beneficial than placebo and is more likely than standard alternatives to provide migraine relief.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested a neurological consult in addition to follow up neurological consults for treatment of her seizure disorder.  Findings:  The physician reviewer found that a neurologic consultation for neurologic complaints is standard of care especially when the PCP feels it is warranted. Several symptoms related to the nervous system can occur independently or dependently of each other and it is the specialist who provides the correct diagnosis. In a majority of cases involving neurologic disorders, PCP providers do not like to prescribe medications especially when there are significant side effects and laboratory studies needed in order to adequately monitor the patient. In 2008, due to the FDA memorandum on the risk of suicide, many providers who did not specialize in neurology but managed patients with epilepsy, began referring the patients to neurologist or epileptologist for standard of care treatment. In addition, the complexity of dosing and polypharmacy coupled with the need to monitor side effects makes the PCP reluctant to manage these patients and instead prefer to send them to the specialist who can provide the best care for such condition.In the absence of proof in this patients records that a neurologist is monitoring her AED usage, a referral to a neurologist is appropriate and within the standard of care. The frequency of visits is contingent upon the neurologic diagnosis and treatment being received. In this case, as the patient is on an AED therapy she should be seen at minimum of twice per year for routine follow ups, and more often as the situation dictates. Therefore, the requested follow up visit to a neurologist is warranted. Moreover, the records suggest an additional reason for referral due to head pain, which is a new complaint and also justifies a neurologic consultation.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested MRI (magnetic resonance imaging) scans of the cervical and thoracic spine for an evaluation of his back and chest pain. Findings:  The physician reviewer found that this patient had back pain that started rather abruptly. It has continued despite physical therapy and anti-inflammatories. The pain is currently being managed with a combination of medication. MRI or CT studies should be considered in patients with worsening neurologic deficits or a suspected systemic cause of back pain, such as infection or neoplasm. Worrisome signs or symptoms that would warrant investigation with an MRI include fever, focal or progressive neurologic findings on physical exam, history of trauma, systemic symptoms, weight loss, history of cancer, chronic steroid use or drug/alcohol use, history of HIV or TB, and suspected ankylosing spondylitis. These imaging studies may also be appropriate when referral for surgery is a possibility. There is no documented evidence of radiculopathy or myelopathy on physical exam, or any of the aforementioned risk factors. MRI scans of the back will often identify incidental findings such as a bulging disc, but these may not in fact be the cause of the pain. Early or frequent use of scanning is not recommended. In one study (Gilbert, et al.), 782 patients were randomly assigned to early or delayed selective imaging. Early use of imaging did not affect overall treatment. In another randomized study (Modic, et al.), 246 patients with low back pain underwent early MR imaging; patients were randomly assigned to a group who were informed of MR findings, or a group in which patient and physician were blinded to the MR results. MR imaging had no measurable value in designing a program of conservative care. Patient knowledge of the MR findings did not improve outcome and was associated with increased anxiety and pain. All told, MRI of the cervical and thoracic spine is not likely to be of clinical value in this setting, and thus, is not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 26-year-old female enrollee has requested for emergency department services  indicating that her condition was  emergent or urgent in nature. Findings:  The physician reviewer found that the patient presented to the Emergency Department for evaluation of painful blisters with surrounding red skin at the end of her nose. Based on the documentation, her presentation appears consistent with a Herpes zoster infection (shingles) with Hutchinsons sign (lesions at the tip of the nose). The importance of Hutchinsons sign is that it signals the involvement of the ophthalmic branch of the 5th cranial nerve. A Herpes infection of the eye can be a serious problem. In light of the patients facial pain and appearance of the lesions, it was reasonable and prudent to go to the emergency department for further evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orencia Clickjet 125 mg/mL. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients seropositive rheumatoid arthritis. The submitted documentation does not support the medical necessity of the requested medication. This patient has been diagnosed with seropositive RA. The records do not indicate the severity. The U.S. Food and Drug Administration (FDA) has approved Orencia for the treatment of patients with moderately to severely active RA, who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors. The current guidelines recommend tumor necrosis factor inhibitors as the first line therapy for active RA. The American College of Rheumatology guidelines recommend methotrexate with or without tumor necrosis factor inhibitors as the next treatment in those who have failed methotrexate alone. Based on the medical records provided, it is unclear that the patient has moderate to severe active RA, as previous records and examinations were not provided. The patients previous treatment has included nonsteroidal anti-inflammatory drugs and Tylenol. Given the patients use of alcohol, methotrexate would be relatively contraindicated. However, travel is not a contraindication to tumor necrosis factor inhibitors use. The medical records fail to demonstrate evidence of the patients failure, intolerance, or contraindications to these medications. As such, Orencia Clickjet 125 mg/mL is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested bilateral derolipectomy of the thighs for treatment of her excess skin.  Findings:  The physician reviewer found that as noted in the medical literature, indications for medically necessary surgery include functional and aesthetic deformity that can be corrected with body contouring surgery (Shermak, et al). However, there must be sufficient documentation to decipher if this is primarily an aesthetic procedure or a functional procedure and to what degree. In addition, Song and colleagues concluded that, Post-bariatric weight loss deformities are diverse, disordered, and often unpredictable. Thus, greater characterization of the abnormal state is needed to help answer the question of cosmetic versus functional. Overall, there is inadequate medical documentation that this patients has a functional problem with the excess skin. Further, the provider has not documented the amount of excess skin, just that this it is present. The possible functional deficits are inadequately described and it is unclear whether the patient has been treated with adequate trials of conservative, non-surgical therapies. The patient complains of open sores and burning of her thighs but this is not supported in the providers examination notes. Given that there is a lack of evidence in the records to support the removal of this patients excess skin as a functional procedure, the requested surgery has not been demonstrated to be reconstructive in nature or medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health conditions.Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not have a comorbid psychiatric or medical condition that would have necessitated a residential treatment setting. He was motivated in his quest for sobriety. At the time of discharge from detoxification, the patient was noted to be in stable condition and motivated for recovery. Aside from a muscle relaxant, the only medication prescribed was quetiapine as needed for anxiety and insomnia. During the episode of illness, the patient had no history of chemical dependency treatment, such as community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  This is significant in this case for two reasons.  First, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Second, there was a lack of evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time.  Thus, residential treatment center services provided were not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry 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.