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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the enrollees cardiac risk.  Findings: Three reviewers found that the patient has hypertension but no diabetes or history of smoking. The patient has no known cardiovascular disease but reported some family history. Her 10 year calculated risk of a cardiovascular event is 1.9% based on American College of Cardiology/American Heart Association (ACC/AHA) cardiovascular risk calculator. This puts her in a low risk category with no recommendation for pharmacologic lipid lowering therapy and only lifestyle and dietary modification as has been done. The patient requested reimbursement for the advanced lipoprotein testing. The Health Plan denied reimbursement for the services at issue as investigational for the evaluation of this patient. Although in situations where there is moderate to intermediate cardiovascular risk but additional clinical risk factors are present, sometimes, a single measurement of these advanced lipid parameters may be useful and indicated in deciding whether to start lifelong statin lipid lowering therapy. However, in this instance, the patient has a low risk for cardiovascular events and the current ACC/AHA guidelines do not recommend starting any pharmacologic therapy (Stone, et al). There is a lack of clear data or published guidelines to suggest that these repeated measurements of advanced lipid profile values provide either prognostic or additional clinical value in low risk patients, as opposed to the current risk factor based guideline recommendations. In this patients case, based on current published ACC/AHA guidelines and published data, repeated advanced lipid profile monitoring does not provide additional actionable clinical information compared to standard profiles and risk assessments. For these reasons, the advanced lipoprotein testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the service at issue is 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 internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atherosclerotic heart disease of native coronary artery without angina. The patient was noted to be taking Zetia 10 mg and simvastatin 10 mg. The provider noted the patients low-density lipoprotein (LDL) level increased to 110 mg/dl while taking Zetia. The patient reported intermittent pain with exertion. His diagnoses included hypertension and hyperlipidemia. The patients low-density lipoprotein (LDL) cholesterol level was 174 mg/dl. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient had tried and failed Zetia, simvastatin, and atorvastatin. The documentation noted that simvastatin caused leg pain. The patient also been treated with stent procedures. The patient has requested authorization and coverage for Repatha Pushtronex injection 420 mg/3.5 ml once a month. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Repatha Pushtronex injection 420 mg/3.5 ml once a month is medically necessary for the treatment of the patients medical condition. Sabatine and colleagues reported, Evolocumab, a monoclonal antibody that inhibits proprotein convertase subtilisinkexin type 9 (PCSK9), significantly reduced LDL cholesterol levels in short-term studies. Navarese and colleagues reported, In conclusion, treatment with PCSK9 antibodies produces profound reductions in LDL cholesterol and lipoprotein (a), with an apparently similar level of safety and an important preliminary signal of survival benefit compared with no anti-PCSK9 treatment. Thus, PCSK9 monoclonal antibody therapy seems to be a safe and effective strategy for patients with dyslipidemia. In this case, there is documentation that the patients LDL was elevated at 110 mg/dl while taking Zetia. There is also documentation of the patients intolerance to at least two statin medications, including atorvastatin and simvastatin. In addition, the patients simvastatin dose was 10 mg per day, which shows intolerance to low intensity statin treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Repatha Pushtronex injection 420 mg/3.5 ml once a month is medically necessary for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: The patient has authorization and coverage for an electrocardiogram (EKG) (CPT code 93000) and a follow-up office visit with a cardiologist (CPT 99213). The U.S. Preventive Services Taskforce does not recommend use of electrocardiography in asymptomatic patients with no history of coronary artery disease. In this patients case, there are no documented recent cardiac symptoms, cardiac physical examination abnormalities, or echocardiographic abnormalities. This patients blood pressure is well controlled, and there are no documented cardiac symptoms or objective cardiac findings to warrant additional cardiac evaluation. Therefore, an EKG (CPT code 93000) and a follow-up office visit with a cardiologist (CPT 99213) are not medically necessary for the evaluation  of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation 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: Medical Necessity
Decision: Overturned

A male enrollee requested  Harvoni 90-400 mg for medical treatment of his chronic hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that according to the most recent 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 (less than 12 months) due to non-liver-related comorbid conditions. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al).  Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni 90-400 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser IFX diagnostic test for evaluation of his Crohns disease. Findings:  Two physician reviewers found that Prometheus Anser IFX testing was ordered to determine Remicade (infliximab) level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. Researchers reported that future prospective controlled studies are needed, especially considering that anti-TNF levels are influenced by several variables that can fluctuate over time and among individuals. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and is 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for 25-Hydroxy Vitamin D Laboratory Testing. The enrollee has a history of hypothyroidism. On an annual exam her chief complaints were fatigue, weight gain, shortness of breath and sleep problems. The physician documented normal physical exam elements, wrote a refill of medications, discussed routine screenings. She had 25-hydroxy Vitamin D laboratory testing as part of her lab work-up. Results showed a normal total Vitamin D level. Her physician indicates her Vitamin D levels were low on a previous test and she was treated with supplemental Vitamin D.  Routine testing for Vitamin D deficiency is not recommended by major professional societies. There is not enough evidence to clearly support or oppose this practice in low risk enrollees, recommending the testing be reserved for those considered high risk, such as enrollees with darker skin, obesity, or poor Vitamin D absorption. There was no evidence in the record of the enrollee having any of these risk factors. The medical literature indicates Vitamin D deficiency testing for enrollees with high-risk conditions, such as renal failure, hepatic failure, and osteoporosis. Studies conclude little benefit is realized from testing those enrollees who do not have risk factors for deficiency. Some literature supports the relationship between Vitamin D levels and enrollees with Hashimotos thyroiditis and Graves disease; however, no professional societies include hypothyroidism as a risk factor for Vitamin D deficiency screening. Additionally, there is no documentation the enrollee had Hashimotos thyroiditis or Graves disease, or that the physician screened her for Vitamin D deficiency as part of the treatment plan for hypothyroidism. Although the enrollee has hypothyroidism, there is no support for Vitamin D testing.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilated cardiomyopathy sequencing panel. Findings:  The physician reviewers found that currently, the value of the genetic testing for dilated cardiomyopathy has not been established in the prospective, randomized, controlled clinical trials for routine use in this clinical setting . Overall, there is a lack of data demonstrating improved health outcomes with use of dilated cardiomyopathy sequencing panel for patients with isolated cases of dilated cardiomyopathy. The American College of Cardiology (ACC) discussed genetic testing for dilated cardiomyopathy in patients with idiopathic hypertrophic subaortic stenosis (IHSS) or Long QT syndrome, but not for patients with isolated cases of dilated cardiomyopathy. Accordingly, the requested dilated cardiomyopathy sequencing panel is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three  reviewers determined that the requested testing is  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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: A 47-year-old male enrollee has requested authorization and coverage for Synvisc One injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has previously benefitted from Synvisc One injections, with symptomatic improvement for over one year. Given this support, the requested Synvisc One injections 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: Upheld

A 47-year-old male has requested approval for a distraction arthroplasty for treatment of his left ankle pain.   Findings:  The physician reviewer found that interest in surgical procedures for ankle arthritis not responding to conservative measures has led to consideration of distraction arthroplasty, and early reports have been encouraging, although the need for additional laboratory and clinical reports has been noted (Tellisi, et al; Morse, et al). Some reports have also considered the possibility of allowing motion as opposed to fixed distraction (Saltzman, et al). Further study is required to evaluate the true value of distraction ankle arthroplasty, since there is currently inadequate evidence based literature supporting its utility (Smith, et al).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. The submitted documentation does not support that the services at issue were medically necessary. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting.In this case, the patient does not meet ASAM criteria for residential level of care. Although she was in withdrawals, they were on the low end of moderate with a clinical opiate withdrawal scale (COWS) score of 13, and a subsequent drop to 8. Mild withdrawals are treated on an outpatient basis. She was capable of controlling her substance use, as evidenced by her reported on and off use history and her ability to abstain for long periods of time. A Suboxone taper is generally considered an outpatient treatment that can be performed in a physician's office with monitoring.The patient was not a danger to self or others; she was not aggressive, violent, or gravely disabled. The patient was cognitively intact and accepting of her diagnoses. There were no severe emotional, behavioral, cognitive, or impulsive barriers to treatment at a lower level of care. The patient was medically and psychiatrically stable and did not need a 24-hour, 7-day structured setting to monitor medication management. There were no acute medical issues that required 24/7 medical or nursing care. Although relapse risk is inherent in this population, it is not a reason to keep a patient in this setting. All aspects of the patients treatment plan, including the as-needed medications and the Suboxone taper, could have safely been provided in an ambulatory setting in conjunction with supports such as the 12-step programs, a sponsor and outpatient counseling. Accordingly, residential treatment center (RTC) services at issue were not medically necessary to treat the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested magnetic resonance imaging (MRI) of the abdomen for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The patient has had an extensive work-up recently for her symptoms, and this testing has been negative.  In particular, evaluation of the gastrointestinal tract has been endoscopically negative.  Additionally, CT of the abdomen and pelvis revealed no abnormality requiring clarification.  The CT allowed for optimal visualization of the diaphragm, pleura, lung bases, spleen and pancreas.  This patient has no history of tumor or infection, and there are no documented indications for MRI of the abdomen in this clinical setting.  All told, the requested MRI of the abdomen is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) scan for evaluation of the enrollees pelvic tumor. Findings:  2/3 of the physician reviewers found that this is a complex medical case involving a solitary fibrous tumor, which is an exceedingly rare tumor.  Considering the rarity of her diagnosis, there is little literature regarding the best means to perform follow-up imaging. However, PET/CT has several benefits over other standard modalities for the evaluation of patients tumor. One advantage to PET/CT is that, not only are masses demonstrated, but there is information garnered by the fludeoxyglucose PET/CT avidity in those masses.  As has been shown in patients with Hodgkins disease, on occasion, one will see a residual mass that is no longer FDG avid. Another advantage of PET/CT scans is that the entire body is scanned simultaneously.  To perform follow-up with routine CT scanning, one would have to perform CTs of the neck, chest, abdomen, and pelvis.  The same issues would occur with MRI scans. In summary, considering the question of changing chemotherapy, and the need to assess disease progression, PET/CT scans are the most accurate means to follow this patient.  Accordingly, PET/CT is likely to be superior to other methods of evaluating this patient.  Final Result: 2/3 of the reviewers determined that the requested services are likely to be 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 reviewer number one is board certified in diagnostic 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 diagnostic 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 three is board certified in diagnostic 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.