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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded foot orthotics for both the right foot and left foot.Custom orthotics have been historically utilized as a conservative standard of care treatment for plantar fasciitis and metatarsalgia. Oftentimes, orthotics will be utilized for bunion and hammertoe pain as well, with specialty pads added to the orthotic to offload painful areas of the feet. Orthotics are useful in the treatment of plantar fasciitis, metatarsalgia, bunions, and hammertoes, as they alter the abnormal biomechanics of the foot, allowing for a more normal foot structure and gait. This will oftentimes alleviate the patients foot pain. In this case, the patient reports painful bilateral plantar fasciitis, difficulty walking, bunion pain and hammertoe pain. The patient is noted to have responded well to custom orthotics therapy in the past. Per the records, her orthotics broke down and became non-supportive. This led to the recurrence of foot pain. Therefore, custom molded foot orthotics for both the right foot and left foot are medically necessary to treat the patients medical condition.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 podiatry 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 brand name Estrace cream. Vulvovaginal atrophy, or atrophic vaginitis, results from estrogen loss and is often associated with vulvovaginal complaints including dryness, burning, and dyspareunia in menopausal patients. The preparations of vaginal estrogen that are available are conjugated estrogens in the form of creams and estradiol in the form of creams, tablets, capsules, and rings. The patients records document isolated vaginal atrophy that requires treatment with only local estrogen therapy. Estrace cream is U.S. Food and Drug Administration (FDA) approved for this patients vulvovaginal atrophy. Additionally, peer-reviewed medical literature supports local estrogen treatment for patients with isolated vaginal atrophy and no vasomotor symptoms. This is consistent with the standard of care to treat this patients symptoms. The provider charted that the patient has responded well to brand-name Estrace cream treatment in the past. However, the patient developed side effects on the generic formulation of Estrace including headache and nausea. Given this report, she meets clinical criteria for treatment of menopausal vaginal atrophy with brand name Estrace cream. Therefore, the requested brand name Estrace cream is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested brand name 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 obstetrics and gynecology 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

A female enrollee requested Botox treatment for treatment of her chronic migraines.  Findings:  Two physician reviewers found that  This patient has documented chronic migraine and had previously failed beta blockers, topiramate, and Cymbalta. In addition, she was previously treated with Botox for chronic migraine with some improvement. In the medical literature, Aurora and colleagues concluded that Botox for treatment of chronic migraine resulted in fewer headache and migraine days per month, which in turn reduced the burden of illness in adults with disabling chronic migraine. Given these findings, the Botox treatment was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested a nephrologist for ongoing monitoring of his medical condition for treatment of his medical condition. Findings:  The physician reviewer found that in this case, a clear plan was conveyed by the nephrologist to the patients PCP. Given the PCPs training in internal medicine, the proposed treatment is within the PCPs expertise and the PCP can be expected to appropriately carry out such instructions. Further, this patients GFR is well above 30. Aside from the low GFR, this patient has no other findings to warrant any further nephrology evaluation. An ultrasound showed normal sized kidneys bilaterally, arguing against renal artery stenosis. The patients simple cyst in the right kidney can be adequately followed by his PCP. Thus, in the absence of a need for a biopsy or any severe metabolic abnormalities requiring the expertise of a nephrologist, follow up by the patients PCP is within the standard of care care in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested deep tissue massage physical therapy for treatment of his medical condition.  Findings:  The physician reviewer found that deep tissue massage physical therapy is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient does not have, through anatomical studies, documentation of a specific anatomical cause for radiculopathy such as recurrent or new herniation in the pattern that would likely produce pain radiating into the dorsum of the foot or complications of instrumentation effecting nerve roots. He likely has adjacent segment changes above the levels of fusion. He will require ongoing attention to deep spinal muscles, the multifidus and erector spinae muscles in order to minimize the risk of progressive adjacent segment disorder over time. It is reasonable that his physical therapy include all of the standard techniques of physical therapies, modality therapies, exercise therapies and massage therapies to be utilized through a skilled physical therapist. This approach will likely maintain core body strength and minimize the possibilities of progression. A medical study endorses the integration of massage therapy as a core healthcare service. In this case, the patient will likely benefit from massage therapies including deep tissue massage for treatment of his low back and leg symptoms.   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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara injections for treatment of the enrollee who has a history of severe plaque psoriasis. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. Due to the location of the psoriatic plaques, phototherapy is also not practical as penetration of the ultraviolet light is difficult in those areas.  Due to her age and child-bearing status, use of acitretin is also not recommended. The provider noted that due to the patients history of malignancy, the patient is precluded from methotrexate, cyclosporine and tumor necrosis factor (TNF) inhibitors. However, the medication requested is also an injectable biologic agent. Like the anti-TNF agents, its use requires a pretreatment protein derivative to ensure that there is no latent tuberculosis infection.  This suggests that Stelara is also immunosuppressive enough to potentially lead to reactivation of latent infection. For this reason, it is not clear that the requested medication is a better option to avoid increased malignancy risk than the standard recommended formulary medications. Also, apremilast does not require pretreatment tuberculosis screening and is likely the safest approach from a malignancy standpoint but the patient did not tolerate this medication due to GI side effects. One option to consider is a slower induction course which would allow for better tolerability.  As such, the documentation provided does not support the use of the requested medication in this clinical setting. Therefore, the requested Stelara injections are not medically necessary for 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 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 parents of a 13-year-old female enrollee have requested Lexapro for the treatment of the enrollees depression. Findings:  The physician reviewer found that the black-box warning on SSRI medications, including Celexa and Lexapro, states that if discontinuing a medication that is known to be effective may increase the likelihood of transient suicidal ideation, in a patient with the history of suicidal ideation, while new and old medications are titrated, this factor should be considered in clinical decision making. Although it appears Lexapro was prescribed by a non-Plan provider, possibly unfamiliar with the Health Plans formulary guidelines, it is in the best interest of this 13-year-old patient to continue on Lexapro. Even if the risk of transient suicidal ideation is low, there is a risk nonetheless. A decision to discontinue a medication that is known to be effective in favor of a formulary medication that is likely to work, but may not, cannot be supported.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with common variable immunodeficiency. Because of her immunodeficiency, she requires monthly infusions of gamma globulin. This is correct medical practice and is well documented to control the frequency of infections in patients with this syndrome. The patient wishes to obtain her therapy at home as opposed to an outpatient center.The issue in this case is the need for home administration of the gamma globulin. The patient has changed health plans and is now required to receive her therapy at an outpatient center. According to the patient, this has caused long delays for her and has required up to 6-8 hours of time.It is not medically necessary for the patient to receive the requested therapy in her home. The patient is not homebound and is employed and apparently on a full-time basis. There is no medical justification for the therapy to be provided in the patients home. The Health Plan is offering appropriate medically indicated care for this patient. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: EE is requesting authorization and coverage for balloon dilation of the Eustachian tubes. The enrollee has eustachian tube dysfunction. Her symptoms include inability to clear her ears, ear popping and bilateral ear pain without drainage. She complains of dizziness, recurrent and moderate in severity, with episodes typically lasting five months. Symptoms worsened with standing still. She has a history of ear pain associated with altitude changes and her ENT-Otolaryngologist diagnosed bilateral eustachian tube dysfunction. She underwent bilateral myringotomy. According to the record, the enrollee had repeated episodes of sinusitis. An audiogram was reported to be within normal limits. Records do not include evaluation of eustachian tube function, the enrollees ability to equalize pressure through Valsalva movement, or imaging studies. The medical literature specifies the use of balloon dilatation requires a definitive diagnosis of eustachian tube dysfunction. A study noted there was some benefit for eustachian tube dilatation for enrollees who have failed medical management. However, there is insufficient objective evidence in the record the enrollee had eustachian tube dysfunction. Additionally, the records show this enrollee had a successful outcome with the use of medical therapy. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in otolaryngology and the other is board certified in otolaryngology and head and neck surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar Gel 400 unit/5 mL vial. Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approves the use of Acthar Gel for the treatment of nephrotic syndrome. Madan and colleagues report that Acthar Gel may benefit patients with nephrotic syndrome who do not respond to or are unable to tolerate first-line therapies, and in patients with advanced disease. Hogan and colleagues report that Acthar Gel may be a viable treatment option for some patients with resistant nephrotic syndrome due to idiopathic FSGS. In this case, given that the patient has failed standard first-line agents and now has some deterioration of renal function, the requested medication is medically indicated. Therefore, Acthar Gel 400 unit/5 mL vial 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 certification in nephrology 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 biventricular pacemaker for cardiac resynchronization therapy for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that based on the records provided, the patient has high rate atrial fibrillation not controlled on medication. She has Class III New York Heart Association (NYHA) congestive heart failure and cardiomyopathy. However her left ventricular ejection fraction was not documented. In this circumstance, if the ejection fraction remains less than 35%, the usual accepted criteria for a biventricular pacemaker are met. Per the providers note dated 7/12/16, the patients ejection fraction is greater than 35%. Given that the patients ejection fraction is not less than 35%, biventricular pacemaker for cardiac resynchronization therapy is not likely to be more beneficial for treatment of the patient's medical condition than any alternative therapy.Final Result: Two reviewers determined that the requested services are 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 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: Upheld

A 61-year-old female enrollee has requested Supartz injections for treatment of her knee pain.  Findings:  The physician reviewer found that this patient has a history of bilateral knee pain and has been diagnosed with osteoarthritis. She has received repeated Supartz injections. Viscosupplementation has been accepted for many years in the treatment of mild to moderate osteoarthritis of the knee.  At this time, no superiority has been identified among the various hyaluronic acid products.  In this patients case, the use of the Health Plan alternatives Euflexxa or Orthovisc would have been medically appropriate.  Although there is documentation of the presence of mild to moderate osteoarthritis in the knees, there is no documentation of prior intolerance to these other agents. All told, Supartz injections provided during the time frame at issue were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) during the colonoscopy procedure at Santa Maria Digestive Diagnostic Center. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, Anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine.  In this case, the patient underwent a routine colonoscopy. She did not have any significant heart, lung, kidney, or liver disease.  There was no documentation of a  history of alcohol or substance abuse. There was no detailed description of a previous history of difficulties with anesthesia or sedation with past colonoscopies.  The patient had an ASA classification score of 2, a Mallampati airway grade of 1, and the records did not indicate that the patient presented with a difficult airway. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, MAC during the colonoscopy procedure at Santa Maria Digestive Diagnostic Center was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram.Findings:  Two physician reviewers found that this tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Final Result: Two reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology 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 authorization and coverage for the LINX esophageal sphincter augmentation for treatment of the enrollees gastroesophageal reflux disease (GERD) and hiatal hernia. Findings:  Two physician reviewers found that the records support that this patient has acid reflux as based on pH recording. However, she also has a constellation of symptoms that are unlikely due to GERD. In addition, implantation of LINX in this patients clinical setting is not recommended given her documented complaint of dysphagia. Further, endoscopy showed no visible or histologic evidence of esophagitis. 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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.