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 the medication Rasuvo for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The America College of Rheumatologys 2015 guidelines for the treatment of rheumatoid arthritis (RA) state The panel also voted that methotrexate (MTX) should be the preferred initial disease-modifying antirheumatic drugs (DMARD) for most early RA patients. For patients with established RA, the American College of Rheumatology continues to recommend methotrexate for all disease activity levels in combination with other biologic agents. In this case, the patient has flaring rheumatoid arthritis which has responded partially to Rasuvo and Xeljanz.  She has failed multiple other DMARDs.  The appeal letter states that the patient has had side effects to methotrexate and Otrexup.  However, the medical records fail to document a trial of either medication or elaborate on what issues/side effects she was having with these medications.  The medical records fail to demonstrate an adequate trial of oral methotrexate and injectable methotrexate with failure of therapy, intolerance or contraindication. As such, the requested medication Rasuvo is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested the medication Lyrica for the treatment of her neck and low back pain. Findings:  The physician reviewer found that Lyrica is FDA approved for treatment of fibromyalgia, epilepsy and neuropathic pain associated with herpes and diabetes based upon sufficient peer-reviewed, randomized, controlled trials. In this case, there is insufficient documentation to establish that the patient has a diagnosis of fibromyalgia. Specifically, there is no documentation of 11 out of 18 bilateral tender points above and below the waist, as would be necessary for a diagnosis of fibromyalgia.  Furthermore, the use of low-dose tricyclic depressants as well as gabapentin are standard of care medication trials for both fibromyalgia and off-label neuropathic pain, prior to use of Lyrica.  These medications have not yet been tried in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy services, 28 fractions with hydrogel placement. This patient presents with a history of Gleason 3+3 prostatic adenocarcinoma. The patient is planned to undergo treatment with proton beam radiation therapy with placement of hydrogel to reduce exposure to normal surrounding health tissue. However, there is a paucity of high quality prospective clinical outcomes published in the peer-reviewed medical literature to support the efficacy of proton beam radiotherapy in the treatment of prostate cancer as compared to active surveillance, prostatectomy, intensity modulated radiation therapy (IMRT) with photons, stereotactic body radiation therapy (SBRT), or brachytherapy. Moreover, the American Society for Radiation Oncology (ASTRO) does not recommend treatment with proton beam radiation therapy for treatment of this patients prostate cancer outside the context of a clinical trial. The records provided for review do not document prior receipt of pelvic radiation or presence of a genetic condition that increases the patients risk for normal tissue toxicity to support an indication for use of proton beam radiation with hydrogel placement. For these reasons, the requested proton beam radiation therapy services, 28 fractions with hydrogel placement, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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: Urgent Care
Decision: Upheld

The parent of a then eight-year-old male enrollee has requested urgent care services for treatment of the enrollee's wrist injury. Findings:  The physician reviewer found that at issue in this case is whether a reasonable and prudent layperson in the parents circumstances would believe the patient was experiencing an urgent medical condition. Urgently needed services are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Health Plans service area. The services rendered out of state on the date in question do not meet the definition of urgently needed services. This patient did not have an unforeseen illness, injury or complication of an existing condition. While the initial injury was unforeseen, the planned removal of the cast was scheduled in advance. The patient had returned to the service area prior to the cast removal and thus the need for a follow-up visit on the date in question was not unforeseen prior to the patient leaving the Health Plans service area. Further, the patients parent indicates the patient returned to the service area shortly after the cast removal. A reasonable and prudent layperson would believe that the patients cast could be removed upon return to the Health Plans service area. The submitted documentation indicates there were no conditions present in the patients circumstances that would cause a reasonable and prudent layperson in the parents circumstances to believe the patient was experiencing an urgent medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy and occupational therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has significant delays in expressive and receptive speech per the DAYC subtest and the RITLS subtests. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. This patients records indicate that he is not yet using words, rather grunting to communicate. An extensive review of the relevant publications including meta-analysis by Law and colleagues reports a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder. Currently there are only a few well-controlled studies that examine the effectiveness of pediatric occupational therapy with well-defined, homogenous populations on outcomes that target participation in everyday life. A systemic review by Polatajko and Cantin concluded that children with difficulty processing and integrating sensory information and difficulties with the performance of daily occupations can benefit from intervention. However, no firm conclusions can be made regarding specific approaches due to the methodological flaws of the study quality and great variability in interventions. The occupational therapy sessions in this patients records focused on sensory processing issues. Since the efficacy of sensory integration therapy has not been objectively demonstrated the requested occupational therapy is not medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested authorization and coverage for orthognathic surgery for treatment of her skeletal jaw deformity.  Findings:  The physician reviewer found that surgical correction of the patients skeletal deformities is required to provide for adequate mastication and to prevent further injury to the temporomandibular joints. These problems cannot be resolved with orthodontic or other dental treatments alone. Pre-operative orthodontic treatment is essential to level and align the dental arches for an optimal surgical result. It is immediately obvious that mandibular osteotomies will be necessary to correct the patients mandibular prognathism. The provider is correct in that a decision regarding the need for maxillary osteotomies, or their configuration, cannot be made until pre-operative orthodontic treatment is completed.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested autonomic function testing (CPT 95943) for evaluation of the enrollee, who has a history of lightheadedness and extreme sweating. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient has had lightheadedness on standing, suggesting orthostasis.  Physical examination revealed a carotid bruit.  No orthostatic vital signs are documented.  Hyperhidrosis is commonly idiopathic, but can be symptomatic of many medical conditions, such as acromegaly, anxiety, cancer, medications, and hyperthyroidism amongst others.  Autonomic neuropathy can cause reduced sweating, and would be unlikely to cause focal palmar and plantar hyperhidrosis.  In this patients case, the clinical documentation is inadequate to suggest significant autonomic dysfunction.  The literature regarding the value of autonomic nerve testing regarding syncope or presyncope is mixed at best, with a lack of high quality, randomized studies.  The clinical notes do not document the need for autonomic testing in this case.  All told, autonomic function testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two 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: All three physician reviewers are board certified in neurology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that the record also included the diagnosis of bipolarity.  The patient was previously prescribed Lamictal, Trileptal, Wellbutrin, Celexa and Prozac, and most recently lorazepam and zolpidem.  However, at the time of the disputed service, the patient was prescribed alprazolam, melatonin and omega-3 fatty acid supplementation.   Genetic testing of methylenetetrahydrofolate reductase was ordered by the primary care provider to assess for a genetic mutation.  The Health Plan has denied reimbursement for genetic testing performed on 9/09/16.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  Trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management.  Further, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines.  In this patients case, the clinical documentation failed to support the necessity of genetic testing.  First, the patients illness burden was steeped in anxiety, not affective symptomatology.  She was not prescribed a mood enhancing medication, while the diagnosis of bipolar illness was uncertain.  There was no evidence of psychiatric consultation or elaboration of the reported non-pharmacologic interventions, such as psychotherapy, biofeedback and toastmasters.  In the absence of a psychiatric evaluation and review of the specific type, setting and duration of psychotherapies, or, the selection, dosing, length of previous psychotropic medication trials and relevant associated circumstances, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition.  The records do not document that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity.  Final Result: All three 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: All three physician reviewers are board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary: A patient requested Synvisc injections in the knees. Findings: The physician reviewer found that the medical evidence does not support repeat hyaluronic acid injections if there is no documentation of significant improvement in symptoms for six months or more. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe knee osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. The Health Technology Assessment for Viscosupplementation for Treating Osteoarthritic Knee Pain concluded that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations, which populations benefit most, and whether hyaluronic acid injections should be combined with other agents to increase effectiveness.  This patient has a history of chronic bilateral knee pain. Current pain and functional assessments are not documented. Clinical examination findings are generally consistent with x-ray findings of mild to moderate bilateral knee osteoarthritis. The patient has undergone a recent corticosteroid injection with insufficient relief. Detailed evidence of other conservative treatment trial and failure is not documented. The patient reports previous Synvisc injections with significant benefit, but there are no details provided relative to pain relief, functional improvement or duration of the benefit. The medical evidence does not support repeat hyaluronic acid injections if there is no documentation of significant improvement in symptoms for six months or more. Therefore, the requested Synvisc injections are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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 authorization and coverage laparoscopy anti-reflux surgery utilizing LINX Reflux Management System treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The three physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Appropriate patient selection is crucial before anti-reflux procedures.  In this case, the patient has acid reflux as based on pH recording. However, it appears the patient has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the patients clinical setting must be approached with caution given documentations of both dysmotility, and of failure to eliminate all acid reflux at the time of initial LINX placement. Based on the clinical information provided for review, the request for laparoscopy anti-reflux surgery utilizing LINX Reflux Management System cannot be deemed likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure 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: All three physician reviewers 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: Overturned

The patient has requested authorization and coverage for Otezla. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Otezla is an oral phosphodiesterase-4 (PDE-4) inhibitor that provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Researchers reported that three recent larger, double-blinded randomized multicenter studies have demonstrated that Otezla is efficacious in the treatment of psoriasis and psoriatic arthritis compared to placebo. The authors observed mild to moderate side effects, with a 75% reduction compared to baseline in Psoriasis Area and Severity Index (PASI-75) or American College of Rheumatology-20 scores. This patient presents with psoriasis and psoriatic arthritis that require systemic treatment. The physical limitations and risks associated with injectable biologics support the use of Otezla for treatment of this patient. Given these findings, the requested Otezla is medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. The submitted documentation supports the medical necessity of the requested medication. Taltz has excellent safety and efficacy profiles. According to the American Academy of Dermatology and the National Psoriasis Foundation, Taltz receives an A recommendation for the treatment of moderate to severe plaque psoriasis in adults. Multiple recent publications have compared Taltz to other psoriasis treatments and reported that Taltz is more efficacious and has better adherence than other biologic medications that are commonly prescribed for psoriasis. There is sufficient support for the requested medication in this clinical setting. Therefore, Taltz 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 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.