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 Stelara. Psoriasis is a chronic inflammatory skin disease which typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, cyclosporin A or the newer biologic agents. Up to 30% of psoriatic patients develop psoriatic arthritis (also known as psoriatic arthropathy), a type of inflammatory arthritis. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Ustekinumab (Stelara) is a human monoclonal antibody that binds to the p40 subunit common to both interleukin (IL)-12 and IL-23. It is indicated for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. The patient has symptoms of plaque psoriasis and psoriatic arthritis that require systemic treatment. Phototherapy is generally not effective for joint inflammation. These factors, as well as the excellent safety and efficacy profiles of Stelara, support the use of the requested medication in this clinical setting. As such, the requested Stelara is medically necessary for treatment of the patients medical condition.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

The parent of a three-year-old female has requested speech therapy for treatment of her autism.  Findings:  The physician reviewer found that there is ample peer reviewed medical literature demonstrating that speech therapy is a medically necessary intervention for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain still exists, and speech therapy can be utilized to improve overall neurologic health, even in patients with underlying neurologic disease. Thus, speech therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills. The evidence is clear that language skills and to a lesser degree, non-verbal skills, improve with long-term application of speech therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. H.P. Acthar is indicated for the treatment of MS relapse. There is a lack of medical literature demonstrating the superiority of H.P. Acthar to high dose oral or high dose intravenous (IV) Solumedrol. H.P. Acthar is typically limited to patients with a moderate to severe clinical MS relapse who do not respond to initial treatment with oral or parenteral steroids, or patients with intolerable side effect issues. In this case, there is mention of agitation, insomnia, and irritability which are typical side effects of steroid therapy. In addition, the records do not support side effects that suggest steroid psychosis. There is no documentation of a recent trial of high dose oral or IV steroids having been provided, and no documentation of significant side effects from IV steroids. There is also no mention of inadequate response to IV steroids for this relapse. Final Result: The reviewers 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: Physician reviewer number two is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested for Bystolic 5 mg  for treatment of his cardiac issues.  Findings:  The physician reviewer found that Bystolic is not currently FDA approved for the treatment of coronary artery disease (CAD), congestive heart failure (CHF) or heart rhythm disorders. While beta blockers as a class have been used to treat these disorders, Bystolic has not been shown to be superior to other beta blockers in the medical literature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Thus, Euflexxa injection series in both knees are medically necessary for the treatment of the 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 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

A 47-year-old male enrollee has requested a Pro-Disc cervical artificial disc (cervical intervertebral disc replacement  ProDisc C  code 22856) procedure for treatment of his neck pain and right upper extremity radiculopathy.   Findings:  Three physician reviewers found that the patient has chronic neck pain and is reported to have radiculopathy, however this has not been confirmed by his history nor his physical examination. The patient has not had any motor or sensory symptoms that would correspond with the C4-5 level. Although he has had some paresthesias in his ring and small finger, these symptoms are not consistent with C4-5 symptoms. Moreover, with regard to the overall efficacy of artificial cervical disc replacement utilizing the ProDisc C, there is no data available in the peer-reviewed medical literature demonstrating the long-term safety and efficacy of the device. Although there are a number of published reports which indicate artificial disc replacement with the ProDisc C is promising, these studies are small in scale and of short duration. A study by the Food and Drug Administration (FDA) to determine the long-term safety and efficacy of the ProDisc C is still ongoing and no results have been published. Therefore, there is inadequate evidence demonstrating that the requested procedure is likely to result in a better clinical outcome for this patient as compared to standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested mental health partial hospitalization program services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The patient was not at risk of harm to herself or others.  She did not demonstrate dangerous or risk-taking behaviors.  Per the submitted records, her mood had improved, and her eating disorder behavior had decreased to episodic.  The patient was taking Lexapro.  She followed her treatment plan and participated in therapy and groups, although she did have difficulty abstaining from exercising.  Her vital signs were stable, and her treatment plan did not require frequent amendments.  She lived at home with her husband, who was actively involved in her treatment.  She demonstrated that she was able to self-manage as evidenced by the reduction in her eating disorder behaviors and medication compliance.  All told, mental health partial hospitalization program services were not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The documentation provided does not support the superior efficacy of the requested procedure in this clinical setting. The patient has GERD as based on pH recording. However, the patient reports benefit to a significant degree from acid suppression treatment with Aciphex, and as such cannot be considered medically refractory to acid blocker drugs. In addition, implantation of LINX in this clinical setting must be approached with caution given the patients reported dysphagia, as well as Barretts esophagus. Given these two latter concerns, LINX is not likely to be more beneficial for treatment of her GERD than the available standard therapy. Final Result: All three reviewers have 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for implantable ambulatory event monitors (HCPCS C1764) and mobile cardiac telemetry (CPT 93285). Based on the records provided for review, this patient presented with symptomatic atrial fibrillation, a patent foramen ovale, and an embolic renal artery thrombosis. In this circumstance, the guidelines recommend treatment with chronic anticoagulation, even without evidence of recurrent atrial fibrillation. This patient underwent cardiac monitoring, which might have yielded additional information about the patients condition. However, current medical guidelines do not support use of continuous real-time monitoring by telemetry services or implanting loop recorders when extended off-line external monitoring is sufficient. The documentation does not demonstrate that this patient has tried these devices and that these devices have failed or were not tolerated. Implanted loop recorders or recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services have not been shown to improve health outcome compared to standard monitoring techniques in this clinical setting. For these reasons, the implantable ambulatory event monitors (HCPCS C1764) and mobile cardiac telemetry (CPT 93285) were not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 subspecialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records noted heterogeneously dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: Three 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: Overturned

A 41-year-old female enrollee has requested intraperitoneal heated chemotherapy for the treatment of her metastatic adenocarcinoma of the appendix. Findings:  Two physician reviewers found that the primary role of intraperitoneal heated chemotherapy has been in the setting of optimal debulking of peritoneal surface malignancy. There is mounting clinical experience in the literature with intraperitoneal heated chemotherapy without debulking for recalcitrant malignant ascites. The cited studies show that there have been excellent results with intraperitoneal heated chemotherapy without debulking in eliminating ascites. Because the volume of this patients ascites is so high that the patient becomes dehydrated with paracentesis, there are no other effective options for this patient. Given the absence of viable alternative therapies in this setting, the use of intraperitoneal heated chemotherapy is medically reasonable and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee has requested social skills group therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that social skills deficits are considered key features in patients with autism spectrum disorder (ASD). However, as noted in Bellini and Peters paper on social skills training (SST) for children with ASD, multiple strategies are often needed to address patients social skills deficits. The authors comment that, Social skills assessment is a crucial first step to SST. Treatment strategies include employing social stories, video modeling, coaching, social problem solving, behavior rehearsal, feedback and reinforcement. The treatments, when determined to be medically indicated, usually involve multiple settings. Williams White and colleagues concluded that the state of research about the effectiveness of social skills groups is still in its infancy. Given that there are multiple treatment modalities available to address social skills deficits in young patients with ASD, as well as the lack of a descriptive social skills assessment for this patient, the medical necessity of the requested therapy as treatment for this patients condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested a biopsy of penile papules for treatment of his medical condition. Findings:  The physician reviewer found that this patient presents with penile lesions of unknown etiology. While sebaceous gland hyperplasia is suspected, other possible causes have not been excluded. The lesions may be due to human papillomavirus infection. Although the STD work-up was normal, this does not rule out human papillomavirus infection as a possible source of the patients lesions. As such, it is medically necessary to biopsy one or two of these lesions to ensure that the lesions do not represent a human papillomavirus infection.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dupixent 300 mg/2 mL.Atopic dermatitis is a complicated immunologic disorder that primarily involves T helper 2 (TH2) cell dysfunction. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and its associated symptoms. The U.S. Food and Drug Administration has approved Dupixent for the treatment of atopic dermatitis. When patients have moderate to severe atopic dermatitis, it is often difficult to manage them with topical agents alone. Systemic therapy is often indicated. The Health Plans denial noted that the patient has not tried and failed at least one oral disease-modifying anti-rheumatic drug, such as cyclosporine. Cyclosporine is a short-term treatment and is not meant to be used long-term to treat atopic dermatitis. It would not be considered standard of care to treat a patient with cyclosporine prior to treatment with Dupixent. All told, Dupixent 300 mg/2 mL is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees 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: Upheld

The patient has requested authorization and coverage for skilled nursing facility (SNF) services. Based on the available documentation, this patient does not require complex wound care or intravenous (IV) medications. The patient does not have a tracheostomy or other daily SNF level skilled nursing need. The patient did not require a SNF admission for his Foley catheter. His pain was controlled. He has not had significant laboratory abnormalities or significant vital sign instability. The patient does not require the specialized skill, knowledge and judgment of a qualified therapist in a SNF. The patient has been limited in his weight bearing status. His physical therapy notes reveal identical functional outcomes that do not support treatment in a SNF. The patient did not require a SNF admission with daily physical therapy or occupational therapy. Skilled nursing and skilled therapy services are not medically necessary on a daily basis. Therefore, the SNF services were not and are 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

A 49-year-old male enrollee has requested a continuous passive motion (CPM) device obtained following knee surgery for post-surgical treatment of his knee. Findings:  The physician reviewer found that the literature does not clearly support the role for CPM after knee trauma surgery. The literature does not clearly demonstrate that CPM improves long-term outcomes when compared to standard postoperative therapy measures. More outcomes data is needed to demonstrate the efficacy of CPM use in cases such as this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested digital breast tomosynthesis (77063) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that per the medical evidence, the addition of breast tomosynthesis to digital breast mammography has been associated with a decrease in call backs and increased detection of small cancers.  The digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.