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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for apremilast (Otezla) for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that the patient has tried and failed therapy with topical steroids for extensive plaque psoriasis. However, there is no documented intolerance or contraindication to treatment with ultraviolet light, acitretin or cyclosporine. The medical records indicate that the patient is a recovering alcoholic, but there is no documentation of abnormal liver function tests to indicate a contraindication to methotrexate. As the patient has not been treated with a preferred systemic agent or phototherapy, the requested Otezla is not medically necessary. 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old male who has a complicated history of hepatitis C and complaints related to the hepatitis C including cryoglobulinemia with renal involvement, neuropathy, congestive heart failure, and skin involvement. The patient has ischemic colon injury, requiring surgery. The patient has failed treatment with interferon, plasmapheresis, and Cytoxan. It is felt by his hematologist and hepatologist that he requires rituximab as salvage therapy. A review of the patients records and applicable literature demonstrates the patient has attempted all appropriate treatments. Based upon the patients available evidence and the patients history the next in line agent to attempt would be rituximab. The evidence presented indicates the patient may have a smoldering B-cell lymphoma; if this is correct, rituximab would clearly be indicated. Regardless, as set forth above the patients history and available evidence demonstrate rituximab is appropriate and indicated. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant. A review of the patients records indicated the possibility of a diagnosis of an intracranial aneurysm, which is common in patients with ADPKD. The risk of bleeding from such an aneurysm is significant. Therefore, any anticoagulation in patients with ADPKD must be undertaken cautiously. Studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Findings:  Two out of three physician reviewers found that studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Final Result: The reviewers determined that the requested tests were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in nephrology, 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: Upheld

A 39-year-old male enrollee requested authorization and coverage of a custom powered reclining wheelchair with an electric elevating seating system for the treatment of multiple sclerosis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old male who was diagnosed with prostate cancer in July 2004. The patient was found to have an enlarged prostate with an elevated PSA of 9.2 on 2/5/04 and 9.9 on 2/13/04. Biopsy results showed adenocarcinoma at both bases of the prostate and a Gleason score of 3+3 on 8/10/04. The patients urologist discussed treatment options with the patient and ordered a CT scan of the pelvis. The Health Plan denied coverage for the CT scan indicating it was not medically necessary for evaluation of the patients medical condition. According to the American College of Radiology, ACR Appropriateness Criteria, pelvic CT has been used rather commonly to preoperatively stage prostate cancer. Unfortunately, multiple studies have indicated a poor accuracy for CT in staging this disease. Overall accuracy in staging was reported as 65% and 67%. Accuracy has been reported as low as 24% with regard to capsular transgression. Even with refined techniques in performing CT, it has been concluded that CT is of little value in staging the local extent of prostate cancer. A recent review of the literature on staging indicates that digital rectal exam, tumor grade, and PSA are more important predictors of spread in high-risk patients than the results of imaging studies. For pretreatment staging of clinically localized prostate cancer with a PSA of 10 or less and/or Gleason score of 2-6, CT of the pelvis has an appropriateness rating of 3 (out of 9) and is not recommended. Based upon the information set forth above, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Based on CALOCUS criteria, this patient does not meet the criteria for RTC level of care. The patient has been at significant risk of harm to others (score 3) as evidenced by the patients past and current passive suicidal ideation, without evidence of active suicidal ideation. The patient has demonstrated moderate functional impairment (score 3) due to intermittent food refusals and superficial self-harm, with limited gains made in a structured treatment setting. The patient has no significant comorbidities (score 1) given the absence of medical or substance use issues. The patients recovery environment is mildly stressful (score 2) as evidenced by her recent transfer from a different RTC facility, and continued discomfort associated with expectations around eating. The patients recovery environment is supportive (score 2) given her parents efforts to take the patient on outings from the RTC and their cooperation with treatment. The patient has shown limited response to treatment (score 3) based on continued food refusal despite extended RTC level of care and multiple prior inpatient hospitalizations. The patient has been incompletely engaged in treatment (score 3) considering her poor insight and judgment, self-harm, and continued food refusals. This gives the patient a composite score of 17, which meets the criteria for high intensity community based services, such as intensive outpatient program (IOP) level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that services at issue were not and 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of her medical condition. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 physician 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

A 33-year-old male enrollee has requested power knee (non-formulary bionic knee prosthetic (L5859)) for treatment of his left transfemoral amputation.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested equipment. The power knee is intended to mimic lost proprioception and muscle function to help patients experience the advantage of reduced effort and unequaled stability. It accomplishes this by providing motor-powered swing phase, stance phase, and sit-to-stand propulsion. Microprocessor-controlled prostheses use feedback from sensors to adjust joint movement on a real time as needed basis. Active joint control is intended to improve safety and function, particularly for patients who have the capability to maneuver on uneven terrain and with variable gait. The choice of the most appropriate design depends on the patients underlying activity level. These devices are equipped with a senor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds. The requested prosthesis is indicated for this patient as there is a demonstrated need for long distance ambulation at variable rates, a need for regular ambulation on uneven terrain and regular use of stairs. Furthermore, this patients physical ability, including the ambulation at faster than normal walking speed and his adequate cognitive ability to master use and care requirements for the technology make him an appropriate candidate for this prosthetic. For the reasons provided above, the requested power knee is medically necessary for the treatment of the patients medical condition. Therefore, the requested equipment should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Danmar soft shell helmet for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that the submitted documentation as well as the medical literature provide support for the requested equipment in this patients case. There is medical literature that documents the association between seizures and head injuries. Head trauma is a common occurrence in patients with intractable epilepsy.  The ramifications of this event can be reduced through the use of a helmet.  In this case, compliance and use of a standard bike helmet would be limited given the patients baseline strength. In the past, the patient has tolerated a Danmar helmet well with reported reduction of head traumas during seizures. To this end, it is reasonable for this patient to continue to use this type of helmet. The patient requires protection from potential risk of head trauma when her seizures occur. For these reasons, Danmar soft shell helmet is medically necessary for 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 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 Jakafi 10 mg for treatment of myelogenous leukemia status post hematopoietic stem cell transplant (HSCT) presenting with graft versus host disease (GVHD). Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) granted a breakthrough therapy designation to Jakafi for the treatment of patients with acute GVHD in June 2016 based on promising preliminary results from two published studies. However, this patient has chronic, not acute, GVHD. Thus, the use of Jakafi is not supported by the current available medical literature. The standard treatment for chronic GVHD is summarized in the literature. Most recently, ibrutinib was FDA approved for the treatment of chronic GVHD providing a 67% response rate. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of the enrollee who has a history of left breast cancer. Findings:  Two physician reviewers found that there is sufficient support in the medical literature for a portion of the services at issue in this clinical setting. This patient meets the National Comprehensive Cancer Network (NCCN) guidelines which recommend BRCA testing for patients who are younger than 45. The BRCA portion of the test would also be indicated in view that the patients mother had ovarian cancer. However, this is a 25 gene panel that includes BRCA within it but also a variety of other suspected risk genes. Though many of these gene mutations are of real interest, and are being studied, for the most part, they have not been found to be significant enough to be the basis for any clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from the major organizations. Accordingly, BRCA1 and BRCA2 of the genetic testing performed were more likely to have been superior over the other methods for evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

The parent of an eight-year-old male enrollee has requested dental anesthesia for treatment of the enrollees dental surgery. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Based upon the documentation provided, the patient has not been able to cooperate with routine dental care. He has severe dental caries requiring fillings and root canals, and experiences daily pain as a result. Further, he is at risk for infection due to untreated severe dental and gingival disease. Although he does not have a diagnosis of psychiatric illness, autism, or global developmental delay, he has been described as mentally challenged, uncooperative and anxious in the documentation submitted. Regardless of underlying diagnosis and age, the patient is unable to comply with standard and routine dental care and restoration. In patients with severe cognitive delay, autism, psychiatric conditions, or behavioral problems, it is medically necessary and appropriate to provide dental evaluation and treatment under general anesthesia. To do otherwise will delay treatment and place the patient at risk of morbidity from his dental disease. Therefore, the medical necessity of the requested services has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old male has requested the ProDisc-L procedure (artificial disc replacement L3-4) for treatment of his low back pain.  Findings:  Three physician reviewers found that the patient has a history of low back pain.  A three-level discogram noted slight to moderate concordant pain at the L3-4 level, slight to moderate concordant pain at the L4-5 level, and no pain at the L5-S1 level. An MRI of the lumbar spine was performed, with comparison to imaging.  The report noted no interval change, with no evidence of neural impingement at any lumbar level.  Physical examination revealed 4+/5 weakness in the left quadriceps and buttock pain that was elicited with forward flexion as well as extension.  In this patients case, the requested procedure is not likely to be of greater benefit than other treatment options.  This patient has chronic low back pain.  The current medical evidence has not established the support efficacy of the requested procedure in this clinical setting.  The medical literature has not established the long-term safety and efficacy of the requested ProDisc-L procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for trametinib. There is a lack of support for the requested medication in this clinical setting. The treating provider provided several references regarding the activity of trametinib for children with low grade glioma (LGG). In one study, two patients with LGG responded, but both had BRAF mutations. In several other publications, children who respond to trametinib have had a BRAF mutation. In addition, there are other more proven options that have not yet been offered. Vinblastine and thioguanine, procarbazine, lomustine and vincristine (TPCV) are well-established regimens for the treatment of LGG in children. Although these regimens are more demanding (require a port and intravenous administration), were proven to work mostly in patients with focal progressive disease, and carry some risk of toxicity, they are well-established, standard regimens and should be considered prior to pursing a targeted therapy in a patient who does not have the target. Trametinib is of unproven efficacy in this setting. The patient is responding to the current regimen. It has not been established that the addition of another agent will provide better disease control, and it might add toxicity. Should additional therapy be required, there are more proven options available. Therefore, trametinib is not likely to be of greater benefit than other available treatment options. Findings:  Two of the three physician reviewers found the requested medication is 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.Final Result: The reviewers determined that the requested medication is 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 reviewers 1, 2 and 3 are board certified in pediatrics with sub-specialty certification in pediatric hematology and oncology 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.