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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested viscosupplementation with Hyalgan injections. Findings  The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. Current medical literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. A systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. There is sufficient support for the requested services in this clinical setting as evidenced by the patients objective findings and history of significant benefit from prior injections. As such, the requested Hyalgan injections of the knees are medically necessary for treatment of this patients knee osteoarthritis.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg every six weeks. Findings:  The physician reviewer found that current medical literature supports dose escalation of Stelara in this case. 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 one year . A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient 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 .  For these reasons, Stelara 90 mg every six weeks is medically necessary for the treatment of this patients Crohns disease. Final Result: The reviewer determined that the requested medication dosage 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation for evaluation of the enrollee who has been diagnosed with ovarian cancer. Findings:  2/3 of the physician reviewers found that the standard therapy for metastatic disease in ovarian cancer is systemic therapy, primarily chemotherapy and/or hormonal therapy. This patient with a cardiophrenic lymph node metastasis is asymptomatic and does not necessitate localized therapy since this treatment modality has not been shown in randomized clinical trials to provide a survival benefit over systemic therapy or observation. Cryotherapy, as used in this patient, was not medically indicated since this patient is asymptomatic and systemic therapy is considered the standard. The standard and the most widely used and accepted approach is external beam radiation. Cryotherapy has not been proven as an advantage over radiation therapy. Accordingly, in this patients case, cryosurgical ablation provided was not likely to have been superior over the standard modalities for the treatment of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology with sub-specialty certification in interventional radiology 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

The parents of a one-year-old female enrollee have requested molding helmet therapy for the treatment of the enrollees dolichocephaly.    Findings:  The physician reviewer found that the patient has documented nonsynostotic dolichocephaly and plagiocephaly and has been receiving care at a specialty craniofacial clinic. Conservative treatment has not been successful in this instance. There is growing evidence in the literature that molding helmet therapy prevents future problems related to the orbit, jaw, ear and related structures. This therapy is thus considered reconstructive and not cosmetic, and is clinically appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested continued acute rehabilitation services for the treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that this patient is demonstrating continued progress in acute rehabilitation and has potential for additional improvement. Appropriate rehabilitation goals are identified and include hygiene, grooming and self-care skills. Acute rehabilitation services should continue for an additional four weeks.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old female enrollee has requested continued use of Protonix and Vytorin for the treatment of her reflux and hyperlipidemia. Findings:  The physician reviewer found that this patient has a history of gastroesophageal reflux disease and has tried and failed a trial of Prilosec. Prevacid was less effective. The patient has been maintained on Protonix with good results since 2001 and no recurrence of her symptoms. There has been no documented trial of use of the formulary alternative Nexium, or an adequate trial using a double dose of the formulary PPIs. Differences have been found between standard doses of PPIs with regard to the onset of symptom relief of gastroesophageal reflux disease and the healing of esophagitis. Despite these differences, there are yet insufficient data to establish the superiority of any one agent over all others across all disease states treated with these agents. There is no documentation in the medical literature indicating superior results with Protonix over the recommended formulary alternatives. Thus, Protonix is not medically indicated for this patient.  The patient has tried and failed treatment with formulary alternatives simvastatin and Pravastatin. Per the reference cited above, the optimal LDL goal of therapy is less than 100. There is no documentation that the patient has tried and failed maximum dose therapy of the formulary statins. Thus, Vytorin is not medically indicated for treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Humatrope Cartridge 12 mg.This patient has an estimated predicted adult height of 53, based on the most recent bone age. This is more than two standard deviations below his mid-parental target height of 58. Without treatment, this patient is unlikely to reach his genetic potential. He failed growth hormone stimulation testing with a peak of less than 10 ng/mL with two provocative tests. This is supportive of growth hormone deficiency, in combination with the poor prediction from the bone age. This patient has open epiphyses and there is still time for him to benefit from growth hormone treatment. The records document obesity and the patient is in early puberty, which explains why his bone age is slightly advanced. The advanced bone age suggests that he will probably not have enough time for catch-up growth in the next few years. There is sufficient support for the requested medication in this clinical setting. Therefore, Humatrope Cartridge 12 mg is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric endocrinology, 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 57-year-old female enrollee has requested emergency services for the treatment of her migraine headache. Findings:  The physician reviewer found that the patients symptoms met the prudent layperson criteria for emergency care. She had severe headache, vomiting and blurry vision of acute onset. A prudent layperson with these symptoms and an average knowledge of medicine would reasonably expect the absence of emergency care to jeopardize their health. In addition, the patient had an abnormal vital sign (significant tachycardia), a red flag for potentially serious or life-threatening conditions.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL Sureclick for treatment of the enrollees pure hypercholesterolemia. Findings:  The physician reviewer found that this patient has an abnormal coronary calcium score indicating the presence of coronary atherosclerosis. In addition, her LDL cholesterol is greater than 190 even while on maximally tolerated therapy, which is evidence for genetic heterozygous familial hypercholesterolemia. Therefore, the patient meets the criteria for use of PCSK9 inhibitors. Accordingly, the requested Repatha 140 mg/mL Sureclick is supported as medically necessary for treatment of this 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: Upheld

The patient is a 30-year-old female who has a complex history of low back pain due to a motor vehicle accident, but also has upper back, neck and shoulder pain that may be due to her large breasts. She has requested authorization and coverage for breast reduction surgery. She is obese and her request was denied on the basis that her body mass index (BMI) exceeds 30. At issue is whether breast reduction surgery (reduction mammoplasty) is medically necessary for treatment of the patients medical condition.This patients musculoskeletal symptoms may or may not be due to macromastia, but referral to a plastic surgeon to make this determination is warranted.  The patients request for a breast reduction was denied on the basis that the patient is obese.  Weight loss however, does not improve the symptoms of macromastia. A study by Collins and Kerrigan confirms that weight loss is unlikely to be of any benefit for this patients upper body musculoskeletal symptoms.Since obesity is a known cause of back pain, musculoskeletal symptoms due to macromastia are often inappropriately attributed to body weight rather than breast size.  Macromastia causes a unique set of upper musculoskeletal symptoms separate and distinguishable from those caused by obesity alone. Multiple studies have confirmed both that obese patients benefit from breast reduction and that weight loss is ineffective as a treatment for symptomatic macromastia.As the patient has not yet undergone a plastic surgeon consultation for consideration of a reduction mammoplasty, the requested surgery may or may not be appropriate for this patient. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. A plastic surgery referral should be authorized. If the plastic surgeon determines the patient is an appropriate candidate for a reduction mammoplasty, the surgery should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left knee. Findings:  The physician reviewer found that Hyaluronic acid injection for osteoarthritic knee pain received U.S. Food and Drug Administration (FDA) approval in 1996 and has become an established part of osteoarthritic knee pain treatment algorithms. Hyaluronic acid injections are generally considered a second-line treatment after exercise, weight loss and simple medications such as NSAIDs, or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individuals. In addition, NSAIDs, acetaminophen, opioids and oral or intra-articular corticosteroids can have systemic side effects and may not be reasonable treatment options for some patients. This patient has undergone gastric sleeve surgery, thus regular use of NSAIDs is not recommended. This patient has had good relief of symptoms with prior knee hyaluronic acid injection. For these reasons, the requested Synvisc One injection in the left knee is medically necessary for treatment of this patients knee pain. 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. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx Melanoma Gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Moreover, its usage is not expected to impact the treatment or outcome of the patients melanoma. As such, the genetic testing (gene expression profiling) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are  board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested transcranial magnetic stimulation (TMS) for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found thatTMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder and has been approved by the U.S. Food and Drug Administration (FDA).   Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice. Further, since the patient has responded well to the therapy in the past, it is reasonably expected that the intervention will improve her condition and prevent a more serious episode of illness. In sum, the request for TMS is medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested inpatient hospitalization services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  The patient was compliant with nutrition in a liquid form, and had gained an adequate amount of weight to be safe for discharge.  She was medication compliant and was not a behavior problem.  The psychologists notes indicate that she has made progress in becoming more engaged with staff and peers.  She has also started performing her activities of daily living with minimal supervision.  Per the medical records, inpatient hospitalization was initially medically indicated.  However, the records fail to demonstrate the medical necessity of subsequent inpatient hospitalization.  There is no indication from the treatment plan that further improvement could be realistically expected.  The treatment provided continued with no change in the strategy that was used.  In sum, inpatient hospitalization was initially medically indicated, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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 parent of a 17-year-old male enrollee has requested continued intensive structured outpatient program services for treatment of the enrollees marijuana dependence and methamphetamine abuse.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the clinical notes, this patient has had sufficient intensive outpatient treatment to become established in group and 12-step treatment.  The medical records note a supportive home environment, and his family members were involved in his treatment.  Although patients may relapse during their movement towards sobriety, this does not always warrant ongoing treatment.  The current medical evidence supports community-based treatment in this clinical setting.  All told, continued intensive structured outpatient program services are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for pembrolizumab (Keytruda) infusions. Findings:  The physician reviewer found that multiple myeloma is a plasma cell neoplasm with many systemic complications including anemia, hypercalcemia, bony lytic lesions, and renal failure. Multi-agent chemotherapy is the mainstay of treatment and is often consolidated with autologous hematopoietic stem cell transplant. By 2017, this patients provider recommended a combination regimen with pembrolizumab, pomalidomide, and dexamethasone that has been demonstrated to be safe and effective in myeloma patients. The U.S. Food and Drug Administration (FDA) has approved Keytruda for metastatic solid tumors that have been identified as microsatellite instability high. However, the FDA has not approved Keytruda multiple myeloma. For these reasons, the Keytruda infusions provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Keytruda infusions provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.