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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar epidural injections at L5-S1. Findings:  The physician reviewer found that American Society of Interventional Pain Physicians  (ASIPP) guidelines for epidural steroid injections addressed approaches to repeat injections (Manchikanti, et al.). The authors noted that repeat injections should be based on, The administration must be based solely on patients response, the safety profile of the drug, experience of the patient, and pharmacological and chemical properties such as duration of action and suppression of adrenals. Regarding procedural outcomes, the ASIPP guidelines state that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be two and a half to three months or longer between each injection, provided that greater than 50% relief is obtained for two and a half to three months, not exceeding four per year, per region. In this case, the patient has lumbar radiculopathy affecting the left greater than the right lower leg and MRI evidence of multilevel degenerative disc disease and joint disease causing moderate grade foraminal stenosis at the lower two lumbar levels. The patient underwent epidural injections, which yielded pain relief for only three weeks, and on the left side with 80% relief for six weeks. The patients provider has recommended lumbar epidural steroid injection six weeks after the last one was completed. Although the patients response to the injection therapy has been clinically relevant, the documented duration of benefit was not at least three months. The ASIPP guidelines state that repeat injections may be considered when the patient reports at least 50% pain relief for at least three months, which was not documented in this patients case. Accordingly, the requested bilateral lumbar epidural injections at L5-S1 are not medically necessary for 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dupixent.Findings: Dupixent is FDA approved for the treatment of moderate-to-severe atopic dermatitis. It is not approved nor recommended for alopecia areata. The recommended dosing schedule for atopic dermatitis is 300 mg every other week (14 days). There was a 300 mg weekly dose studied in the original clinical trials, but it consistently failed to demonstrate any superiority over the 300 mg every other week schedule. Moreover, there are no well-regarded existing consensus/treatment guidelines that advocate for increasing the dose of Dupixent to try to achieve greater clinical benefit in this setting.In this case, the patient has a history of atopic dermatitis that has been treated with Dupixent. The patient has had breakthrough flares with the conventional, recommended dosing schedule of 300 mg subcutaneous every 14 days and has requested an increase in the frequency of dosing. However, as noted above, when weekly dosing was studied in the original clinical trials it consistently failed to demonstrate any superiority over the 300 mg every other week schedule. There are also no well-regarded existing consensus/treatment guidelines that advocate for increasing the dose of Dupixent to try to achieve greater clinical benefit in this setting. Therefore, the requested medication, Dupixent, is not medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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 a full body positron emission tomography (PET) scan for medical evaluation of her cancer.   Findings:  Three physician reviewers found that at the recommendation of the National Oncology PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its recommendation for coverage for PET scans in patients with nearly every type of solid tumor.   The full body PET scan was within the revised CMS guidelines and was likely to have been more beneficial than any available standard imaging modality.  Final Result:  Three reviewers have determined that the diagnostic procedure at issue was 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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 20-year-old male has requested coverage for past residential treatment services for treatment of his polysubstance dependence and anxiety.  Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry (AACAP) recommends the least restrictive setting in the treatment of adolescents with substance use disorders. In fact, this recommendation receives their strongest endorsement, meaning adherence is expected more than 95% of the time, and when this minimal standard is not applied clinically, documentation should support the rationale for the deviation in care.  The AACAP also states although residential programs, including therapeutic communities, have a place in the range of setting options, community intervention settings, if feasible, may offer optimal generalization of treatment gains. In the patients case, there is no evidence that he had participated in a community and/or school-based intensive outpatient or partial hospitalization program following his treatment at the Second Nature Wilderness program. Accordingly, and in the absence of other clinical information, transition from that nearly three-month program to an intensive outpatient program would have been consistent with accepted standards of practice. Further, review of the residential treatment facilitys records reveals no mention of psychiatric instability such as suicidality, homicidal ideation or psychosis that would warrant 24-hour supervision during the period at issue. Moreover, the psychopharmacological treatment the patient received (venlafaxine, trazodone, melatonin, hydroxyzine, and ramelteon) did not exceed a level of complexity appropriate for outpatient care. In sum, the submitted documentation does not demonstrate that the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old female with degenerative arthritis of the right knee. She has undergone two previous Synvisc injections with good pain relief. She is seeking authorization for another injection. The Health Plan has denied authorization for another Synvisc injection.The Health Plans denial should be upheld. There is no data to support the efficacy of another Synvisc injection for this patient. In addition, there are other modalities available for the patient with established efficacy. There is very good potential the patient will obtain benefit from such treatments as steroid injections with physical therapy and NSAID treatment. Because there is no data to support another Synvisc injection for this patient and there are other effective treatments available for this patient, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested intensive outpatient program (IOP) services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that The American Psychiatric Association (APA) practice guideline states that IOP may be helpful for patients with severe treatment resistant OCD. The records indicate that this patient is doing well at the IOP level of care and is only just beginning to identify her paranoid ideations. The patient remains at the stage where social anxiety, OCD, and paranoia still impede her ability to perform activities of daily living. Thus, she needs more time in the therapeutic milieu that the IOP offers so that she can continue challenging these thoughts in a safe environment. All told, continued treatment at the IOP level of care from the date indicated forward is appropriate to treat the patients condition, could not be managed effectively at a lower level of care, and is thus medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A sixty-two year-old male with stage T2, N1, M0, poorly differentiated squamous cell cancer of the right tonsil with right neck node metastases is requesting coverage for thermoradiation therapy.  Reviewers Findings:  One of the three reviewing physicians found that thermoradiation therapy has been approved by the Food and Drug Administration. It has been used at several centers for treatment of cancer of different sites with some encouraging results. Two of the three reviewing physicians found that thermoradiation therapy may be superior to standard external beam radiation therapy in select patients, but this patient does not meet the criteria that would suggest superiority of thermoradiation therapy over standard external beam radiation.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested custom orthotics for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  There is a lack of support in evidence-based, peer-reviewed literature demonstrating the effectiveness of custom orthotics over pre-fabricated orthotics in the treatment of plantar fasciitis.  In this case, the patient has been prescribed a conservative treatment trial, including over-the-counter orthotics.  The medical records do not document that he has failed to improve with the use of pre-fabricated orthotics to support the medical necessity of custom orthotics at this time.  Therefore, the requested custom orthotics are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power seat elevation for the approved Group 3 powered wheelchair. Researchers describe facioscapulohumeral muscular dystrophy as a common form of muscular dystrophy that presents clinically with progressive weakness of the facial, scapular, and humeral muscles, with later involvement of the trunk and lower extremities.  The patient has requested power seat elevation, as he reported that this would improve his ability to transfer, and he does not like using a Hoyer lift. In this case, the documentation indicates that the patient is dependent for transfers, and there is no indication that he could safely perform independent transfers. The DME evaluation noted that the Hoyer lift was the safest mode of transfer. Due to the patients minimal upper extremity range of motion and his dependence for transfers, the requested modification is not medically indicated in this case. Therefore, power seat elevation for the approved Group 3 powered wheelchair is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested modification 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 physical medicine and rehabilitation 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 Rituxan for treatment of the enrollees seropositive rheumatoid arthritis.Findings:  The physician reviewer found that For the treatment of rheumatoid arthritis, the 2015 American College of Rheumatology (ACR) guidelinerecommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  A second TNFi with or without MTX of non-tumor necrosis factor biologic with or without agent is recommended over Xeljanz. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA.  TNFi therapy has superior efficacy when used in combination with MTX, based on high quality evidence. There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi.  Smolen and colleagues noted the following, Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors.  There are very limited studies that are looking at the failure of first TNFi agent and a different biologic agent.  In this case, the patient has both active seropositive RA and active MG. The documentation shows that this patient has tried and responded to Enbrel but stopped due to worsening alopecia. The records note previous use of methotrexate, but the records do not indicate as to why this was stopped. There is a lack of large randomized controlled trial looking at the use of Rituxan and MG.  There are case reports showing improvement in MG patients and tolerability, but larger studies are needed. The medical literature do not show that TNFi is contraindicated in MG. As such, the medical records fail to demonstrate the medical necessity of Rituxan in this patients case. Therefore, Rituxan is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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 62-year-old female enrollee has requested for Celebrex for treatment of her sacroiliitis.  Findings:  The physician reviewer found that Emery and colleagues noted that Celebrex has similar efficacy in terms of analgesic and anti-inflammatory efficacy when compared to other non-steroidal anti-inflammatory drugs (NSAIDs). There have been multiple studies, as reported by Silverstein and colleagues, which have shown a decrease in gastrointestinal toxicity with the Celebrex and other COX-2 inhibitors. However, Bertagnolli and colleagues data and that from other large, long-term studies, have associated use with an increased risk of cardiovascular problems, myocardial infarction and stroke. Since the COX-2 inhibitors have an increased cardiovascular risk, their use should be avoided unless the patient was at higher risk for gastrointestinal toxicity (i.e., 65 years or older; a prior history of ulcer disease or gastrointestinal bleeding; or concomitant use of Coumadin, Plavix, or glucocorticoids), of which there is no indication from the records provided for review.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old female enrollee has requested growth hormone therapy (Humatrope) for treatment of the enrollees idiopathic short stature.  Findings:  Three physician reviewers found that the patients height was -1.94 standard deviations below the mean for age. Both of the patients parents are 53, leading her previous provider to find that her condition reflected genetic short stature. The medical records note that growth hormone therapy was initiated. In this patients case, the medical documentation indicates familial short stature. Additionally, growth hormone therapy is generally approved for patients shorter than -2.25 standard deviations from the mean. When children with idiopathic short stature treated with growth hormone therapy are compared to untreated short children, the results indicate no difference in school achievement, psychosocial measures or quality of life. Thus, utilization of growth hormone therapy is not supported by scientific outcome data in this particular setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested positron emission tomography/computed tomography (PET/CT) scan for evaluation of her anal squamous cell carcinoma.  Findings:  Three physician reviewers found that this patient has a history of anal cancer with known recurrent carcinoma.  There is ample support in the peer-reviewed literature for the use of PET/CT scan in the evaluation of possible recurrent or metastatic anal cancer.  As noted by Grigsby, the requested diagnostic procedure is an imaging modality which greatly affects the management of patients with anal cancer.  Conventional imaging such as MRI and CT cannot provide the metabolic information of a PET scan.  Conventional studies may show normal-sized lymph nodes.  However, on a PET scan, the lymph node  may show increased uptake indicating recurrent/metastatic disease.  The outcome of the requested PET/CT scan in this patients case will have a direct impact on the treatment plan.  In sum, the requested PET/CT scan is likely to be more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollees allergic rhinitis and asthma. Findings:  The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is within the standard of care for providing immunotherapy injections to a patient who is symptomatic with asthma and allergic rhinitis. Review of the record shows sufficient documentation to support the increased dosing. There was allergy skin testing done with positive findings for several allergens. Clinic notes from provider indicate that the patient was actively taking multiple medications for rhinitis and asthma. The provider also stated that Allergan immunotherapy has been effective for improvement of the patients rhinitis and asthma. Clinic notes from provider report the severity of her condition indicating that the patients symptoms flared when injections were given monthly rather than weekly, and her parent stated that when the patient does not receive weekly injections then she gets sick. The provider stated that immunotherapy was indicated for weekly intervals due to increased symptoms of asthma and rhinitis indicating and that the patient had effective results on immunotherapy when dosed more frequently than every month. As per the allergy practice parameters on dosing, immunotherapy level of efficacy can be determined by measuring objective and subjective parameters. Objective measures, such as an increase in allergen-specific IgG levels and decreased skin test reactivity, as measured by means of skin test titration, are changes generally associated with effective immunotherapy but, at present, are not practical for routine clinical use. Most providers rely on subjective assessments demonstrated by a reduction in medication use as well as improvement in symptoms. An increase in serum allergen-specific IgA and IgG levels, particularly of the IgG4 isotype, has also been associated with immunotherapy. Given this support and this patients response to previous weekly injections, the requested pollen and allergy injections performed weekly is medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in allergy and immunology 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 parents of a six-year-old male with a diagnosis of autism are requesting continued authorization of individual speech therapy. The record also indicates that the patient is receiving speech therapy through the school system one hour per week along with the individual speech therapy.Reviewers Findings:The reviewing physician found that the literature reveals there are no outcome studies or randomized controlled studies demonstrating that individual speech therapy improves pragmatic speech and communication in patients with autism or that an increased frequency of speech therapy is more beneficial than the standard one time per week therapy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a one-year-old male with a history of torticollis with positional plagiocephaly are requesting authorization of physical therapy.Reviewers Findings:The reviewing physician found that based on the submitted therapy notes and progress report, it appears that the patient has made sufficient gains and therefore, it is medically appropriate to transition him to a home program performed by his parents.  The reviewing physician found that the Health Plan denial should be upheld.