Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested rituximab infusion therapy for treatment of her myasthenia gravis.  Findings:  Three physician reviewers found that in this patients case, the requested therapy is likely to be superior over other available treatment options.  Although rituximab is not considered a first-line therapy for myasthenia gravis, there is adequate literature supporting its use for this condition.  Per the submitted medical records, this patient has failed multiple first-line therapies for myasthenia gravis.  As undertreated myasthenia gravis can result in severe disability, a trial of rituximab is indicated and is likely to be more beneficial than previous therapies.  Thus, rituximab infusion therapy is likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a nebulizer for treatment of his asthma. Findings:  The physician reviewer found that there are step-wise recommendations and guidelines for controller medications, medications for acute exacerbations, and management of worsening illness. The goal of asthma control is providing benefit with the least amount of medication. The use of inhaled corticosteroids is universally supported, and may need to be augmented with leukotriene modifiers, long-acting inhaled beta-agonists, and at some point, biologic modifiers. When used for management of obstructive pulmonary diseases such as asthma, the provider must consider use of metered dose inhaler with and without a reservoir or spacer device and decide whether it is sufficient for the administration of needed inhalation drugs. The medical literature does not wholly support one method of delivery over another. According to a recent Cochrane review by van Geffen and colleagues, there is lack of evidence supporting one method of delivery over another for exacerbations of chronic obstructive pulmonary disease. In a second earlier study with asthma patients, inhaler and nebulizer were considered approximately equivalent. In practical terms, however, when a child is having an acute exacerbation with distress, it may be more efficient to administer inhaled medication with a nebulizer if that is what the child is accustomed to using. In this patients case, the parent considers the nebulizer to work better for the patient when he is having an acute exacerbation and he is in need of delivery bronchodilator therapy. Given the significant morbidity and mortality still associated with asthma, cooperation on the part of the patient is essential. Therefore, in this clinical setting, the requested nebulizer is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in pediatric critical care 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: Upheld

A 28-year-old male enrollee has requested lumbar fusion surgery with discectomy for treatment of his low back pain. Findings:  The physician reviewer found that lumbar spinal fusions are indicated for instability from trauma, tumor or infection, or iatrogenic causes. This procedure is rarely warranted for routine discectomy or abnormal results of radiology without appropriate clinical findings (Aebi). Improvement can be expected with established indications, such as spondylolisthesis, but patients with chronic low back pain experience less improvement (Carreon and colleagues), and fusion is no more effective than intensive rehabilitation for non-radicular back pain (Chou and colleagues). There is a need for further randomized, controlled trials to clarify the efficacy of lumbar spine fusion in this setting (Gibson and Waddell). Because post-discography surgical outcomes have been inconsistent, the validity of discography as an indication for fusion remains controversial (see Pneumaticos and colleagues). Disc injection may produce pain in patients with no history of low back symptoms, but who have undergone posterior iliac procedures (see Carragee and colleagues). Abnormal discograms have been reported in a significant number of asymptomatic patients (see Walsh and colleagues).
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 61-year-old female who has been diagnosed with osteoarthritis of the right knee. On 8/19/19, the provider noted the patient had been treated with a right knee arthroscopy with partial meniscectomy and chondroplasty in January 2018 and a cortisone injection in June 2018. The provider noted the patient had previous success with an intra-articular Gel-One injection in September 2018. On 8/19/19, the patient reported intermittent right knee pain, stiffness, and swelling. The patient has requested authorization and coverage for Orthovisc (or any other recommended hyaluronic acid injection) for the right knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc (or any other recommended hyaluronic acid injection) for the right knee is medically necessary for the treatment of the patients medical condition. The physician reviewer found that the review of 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. A clinical trial by Campos and colleagues 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. She has tried and failed arthroscopic surgery and corticosteroid injections, with the alternative being a total knee arthroplasty. Furthermore, she had benefitted from prior viscosupplementation injections. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc (or any other recommended hyaluronic acid injection) for the right knee is medically necessary for this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male enrollee has requested Humira Pen 40mg every 14 days for treatment of his stated conditions of inflammatory spondylopathy and ulcerative colitis.  Findings:  Three physician reviewers found that the provided medical records describe a patient with severe ulcerative colitis and colitic arthropathy, no longer controlled with high-dose Remicade. Remicade is typically only prescribed if the patient has already failed conventional treatments, including prednisone, methotrexate and agents such as Dipentum. It is standard and appropriate practice when faced with loss of benefit from a tumor necrosis factor (TNF) inhibitor, to then switch to a different TNF inhibitor, as this has often proven to be effective. Patients treated with Remicade may develop human anti-chimeric antibodies (HACA) as an immune response to the medication itself, and this may neutralize the benefit of the drug. Switching to fully humanized Humira can then prove to be effective, as it is much less prone to immunogenic responses by the patient, and would not cross react with the antibodies generated by the Remicade. This is a phenomenon which has been seen repeatedly in clinical practice, and which is supported by the above cited peer reviewed medical literature references, which describe a beneficial response to Humira when used to treat patients who have failed Remicade previously. Therefore, the requested Humira treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg injector.Plaque stabilization, prevention of progression or occasional plaque regression can be seen with aggressive lipid lowering therapy. Generally, statin therapy would be recommended as standard of care. In this case, the patient has been diagnosed with hyperlipidemia. With intensive lifestyle modifications, nutritional supplements and ezetimibe, he has been able to decrease his LDL to 94. Based on current risk profile, he has a 10-year cardiovascular event risk of 6.7%, and recommendations would be for moderate dose statin therapy to lower his LDL to 70 or below. The risk is further enhanced given the established coronary disease noted on the 2019 CTA. Unfortunately, he is intolerant to low doses statin medications (rosuvastatin 10 mg and simvastatin 20 mg). As he is not at goal and is intolerant of recommended statin medication, the use of an alternative lipid-lowering agent (Repatha PCSK9 inhibitor) is medically appropriate. Thus, the requested Repatha SureClick 140 mg injector 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee's representative has requested reimbursement for transcranial magnetic stimulation (TMS) services for treatment of the enrollees major depressive disorder.Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS is approved by the U.S. Food and Drug Administration and is well tolerated with fewer barriers than electroconvulsive therapy. TMS has the endorsement of the American Psychiatric Association (APA) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In addition, the standard of care does not require multiple medication trials prior to TMS therapy. In this case, the patient had pursued, but not exhausted other standard therapies used to combat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represented a safe and appropriate treatment consistent with good medical practice and was reasonably expected to improve the patients condition at the time of service. As such, the TMS services provided  through was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old woman who has a progressive neurological disease. In an evaluation by the patients physician in October 2003, he reported the patient had been bitten by a tick in California in 1986. In 1988 she had episodic loss of bladder control. In 2000, she had episodes of loss of balance followed by weakness, spasticity, fatigue and rigidity. She has had progressive weakness, muscle spasms, and loss of coordination in the last two years. When assessed by her physician, the patient was dependent on a walker.In a follow-up visit in January 2005, the patients physician noted the patient had increasing problems with speech, fatigue, and muscle spasms. He reported a tremor at rest and slurred speech. He noted plans for Mepron and Biaxin therapy, and stated that the Rocephin should be continued.Laboratory tests include a single Babesia WA-1 serology that was positive at a low level [1:640]. A Lyme IgM Western Blot performed in October 2004 was not positive by CDC criteria. IgG and IgM tests for Babesia microti performed at the same time were negative. A Babesia FISH study was also negative. There is a note that a Bowens test for Lyme was positive.In June 2004, the patients provider ordered Rocephin via a PICC line. The patient was to continue on Rocephin until December 2004.A request has been made for reimbursement for the Rocephin injections the patient received. The Health Plan indicates the medication at issue was not medically necessary for treatment of the patients medical condition.Review of the submitted clinical information reveals no evidence of Babesia or Borrelia infection. In addition, the Bowen test for Lyme disease has not been validated and is not an accepted component of the serological diagnosis of this disease. Furthermore, the Western Blot for Lyme disease that has been provided was an IgM, which is usually positive rather soon after infection. This test was negative by CDC criteria. Moreover, evidence of an IgG test, which is more reflective of distant infection, has not been provided. The Babesia WA-1 test was a single determination in a patient who has clinical symptoms, which do not fit a diagnosis of Babesiosis.The patients clinical findings are not consistent with Lyme disease. The patient has a progressive neurological disease that is clinically not consistent with nervous system Lyme disease. Even if there was clear documentation of Lyme disease, the maximum recommended duration of treatment with Rocephin is 30-60 days. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested for Euflexxa injections for treatment of her temporomandibular joint (TMJ) pain.  Findings:  Three physician reviewers found that osteoarthritis of the TMJ is defined as the breakdown or degeneration of articular bone and soft tissue due to excessive joint loading or normal wear and tear. As a consequence, breakdown products including inflammatory mediators and lysozymes lead to secondary synovitis and capsulitis resulting in joint tenderness and pain. The treatment of DJD is challenging and advanced cases have been treated with open joint surgery with a variety of reconstructive techniques. Less invasive techniques that offer decreased morbidity have also been shown to be successful, such as sodium hyaluronate injections. These injections have clearly been an effective treatment for this patient and should be authorized at reasonable intervals for as long as there is sustained efficacy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. The authors found that in the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. Yu and colleagues compared proton beam radiation therapy versus IMRT in regards to early toxicity among patients with prostate cancer. There was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, however this difference disappeared by one year. In addition, the position statement by the American Society for Radiation Oncology (ASTRO) state At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. For the reasons provided, proton beam radiation therapy has not been established as medically necessary for the treatment of the patients prostate cancer. 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 radiation 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: The patient has requested authorization and coverage for Lyrica for treatment of the enrollees low back pain. Findings:  The physician reviewer found that The records provided for review document that this patient developed chronic back pain radiating to both lower extremities. The patients primary pain generator is musculoskeletal and not neuropathic, post-herpetic or from fibromyalgia. Lyrica is recommended in case of fibromyalgia, neuropathic pain and post-herpetic neuralgia. Therefore, the requested Lyrica is not supported as 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 neurology with sub-specialty certification in neuromuscular 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: Urgent Care
Decision: Overturned

A 22-year-old male enrollee has requested emergency services (a magnetic resonance imaging of the left knee) for the treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This case meets the prudent layperson criteria for emergent care. Severe swelling and extreme pain in a newly traumatized knee joint constitute valid criteria for a prudent layperson to seek immediate medical attention. In addition, the treating orthopedic surgeon agreed that this problem was emergent due to his findings of pain, swelling, and instability of his left knee and he recommended an MRI of the injured knee to be done as soon as possible. Since the following Monday was the earliest possible date to perform the MRI, it was reasonable the imaging was done on that date. The provider documented the necessity of the MRI was to to rule out any ligament damage or torn cartilage, as this would determine his appropriate care and treatment options.  Thus, the MRI performed was emergent in nature such that a prudent layperson would have followed the advice of his provider and undergone the MRI at issue for evaluation of his traumatic injury for proper diagnosis and treatment.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for voice feminization therapies. The enrollee has gender dysphoria of adulthood. She has been living full-time as a woman and began hormone therapy. However, records indicate her gender dysphoria has persisted due to the low pitch of her voice, resulting in anxiety, depression, and agoraphobia. The enrollees transgender health consultant reports the enrollees gender is frequently misidentified due to her low voice, and this exacerbates the enrollees symptoms of gender dysphoria. The consultant indicates transgender women face the highest rates of suicidality and the enrollees pitch of her voice leaves her vulnerable to transphobic violence. Literature shows voice is highly related to gender. Literature notes the treatment goal for transgender people who present with voice and communication complaints is to help them achieve a gender congruent voice in an efficient and safe manner. Treatment can be accomplished through behavioral and medical or surgical intervention. Literature describes the importance of a gender congruent voice on psychosocial well-being and quality of life.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The Psy.D reviewer is board certified in psychology 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: Upheld

A 44-year-old male enrollee has requested physical therapy and physiotherapy for the treatment of his pelvic pain syndrome and prostatitis.  Findings:  The physician reviewer found that while the relevant medical literature does demonstrate some response to the therapies at issue, a placebo effect likely plays a role. Therefore, further studies are needed before the efficacy of these modalities can be sufficiently established.