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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for first metatarsophalangeal joint (MPJ) cheilectomy, debridement and capsular release with Cartiva implant of the left foot. Based on the records provided for review, this patient underwent first MPJ cheilectomy with Cartiva implant of the left foot for hallux rigidus of the left first MPJ. The Cartiva implant is a synthetic implant placed within the first MPJ to treat osteoarthritis and hallux limitus. Current medical literature suggests that additional studies are needed to determine whether the Cartiva implant can provide superior health outcomes when compared to standard of care approaches such as arthrodesis of the first MPJ. Long-term data have demonstrated the safety and efficacy of arthrodesis with excellent and reproducible results. Therefore, first MPJ cheilectomy, debridement and capsular release with Cartiva implant of the left foot was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the first MPJ cheilectomy, debridement and capsular release with Cartiva implant of the left foot (CPT code 28291) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 podiatry 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:  An enrollee has requested authorization and coverage for Dupixent (Dupilumab Subcutaneous Solution Pen-injector 300 mg/2 ml every 14 days) and a loading dose of Dupixent 600 mg filled by specialty pharmacy and self-administered at home by the patient. Findings:  The physician reviewer found that Holguin and colleagues indicate that Dupixent is appropriate as add-on therapy in patients with asthma that is uncontrolled on medium-to-high dose inhaled corticosteroids (ICS) and long-acting beta 2-agonists (LABA). The authors further reason that the add-on therapy may reduce exacerbations, improve asthma symptoms, and lung function. In this case, the patient does not have a history of uncontrolled asthma. The records indicate that the patient has good control of her symptoms on a low dose of Advair and has not reached maximum inhaled corticosteroid use. In addition, she has no history of exacerbations requiring oral corticosteroids. Therefore, the requested Dupixent (Dupilumab Subcutaneous Solution Pen-injector 300 mg/2 ml every 14 days and a loading dose of Dupixent 600 mg filled by specialty pharmacy and self-administered at home by the patient is not medically necessary for treatment of the 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 and 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sunosi. Findings: The U.S. Food and Drug Administration (FDA) has approved Sunosi for the treatment of patients with excessive daytime sleepiness associated with narcolepsy or OSA who are actively treated with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) but have residual excessive daytime sleepiness. However, Sunosi has not been shown to treat underlying obstructive sleep apnea (OSA). In addition, Sunosi has been determined to have potential side effects on the cardiovascular system, which dramatically increase in patients with untreated or undertreated OSA. Overall, there is a lack of studies demonstrating the safety and efficacy of Sunosi in the treatment of patients with severe OSA as in this patients clinical setting. On review of the medical literature, Sunosi is not indicated for treatment of this patients excessive daytime sleepiness secondary to untreated OSA. Therefore, the requested Sunosi tablets are not medically necessary for 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 subspecialty certification in sleep 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213). While there is benefit in BRCA2 testing in males at risk for cancer, a full genetic work-up is not consistent with the current recommendations. This patient has no known personal risk of cancer. His mother has a history of cancer with a BRCA2 mutation. Given the presence of a specific genetic mutation in his family, testing of the specific mutation identified in his mother is appropriate. Males with BRCA2 mutations are known to have increased risk of breast cancer and prostate cancer. Identification of a BRCA2 mutation in this patient would lead to increased screening or higher index of suspicion should symptoms develop. The records do not support full panel genetic testing as requested. The patient has been approved for BRCA2 testing (CPT code 81217). Thus, the BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213) are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the BRCA1 and BRCA2 genetic tests (CPT codes: 81408, 81479, 96040, 81162, 81211, and 81213) are not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in genetics 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 the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD) and hiatal hernia.  Two physician reviewers found that currently, there is a paucity of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. An evidence review concluded that the long-term safety and efficacy of LINX  both alone and in comparison to current GERD therapies  remains to be determined. In addition, another best-evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have also been reported in the period after U.S. Food and Drug Administration (FDA) approval. Given these findings, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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 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

A 47-year-old female enrollee has requested reimbursement for Supartz injections for treatment of her hip osteoarthritis and acetabular labrum tear.  Findings:  The physician reviewer found that it is not likely to be beneficial for this patient to have intra-articular hyaluronic acid injections with Supartz to her symptomatic right hip. The attempts at conservative care including extra-articular and intra-articular measures have been appropriate due to the age of the patient. Extra-articular procedures including repair of labral tears are likely to postpone total hip replacement.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tresiba Flextouch U-20-200/ml for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Hypoglycemia is a frequent byproduct of tight glycemic control for diabetic patients, and may impact a patients quality of life. Despite advances made with basal insulin analogs, many patient using these insulins achieve less than optimal glycemic control or are at risk for hypoglycemia. Until recently, the available basal insulin analogues have failed to deliver steady, peakless, continuous insulin for greater than 24 hours and were associated with frequent hypoglycemia.  Newer insulin products have recently become available for use in the United States, including the ultra-long-acting insulin degludec (Tresiba).   These new insulins demonstrate different pharmacokinetic/pharmacodynamic profiles and longer durations of action in comparison to earlier insulins, which may lead to potential benefits, including decreased frequency of hypoglycemic episodes. Per the records, this patient has responded well to a trial of Tresiba and has experienced a decrease in his frequency of overnight hypoglycemia.  The medical evidence supports the requested medication in this clinical setting. Final Result: The reviewers 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 endocrinology, diabetes and metabolism 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 Xeljanz XR 11 mg tablets. Findings:  The physician reviewer found that treatment guidelines for rheumatoid arthritis state that when at patients disease activity is moderate to severe, despite the use of disease modifying anti-rheumatic drug (DMARD) therapy, then a tumor necrosis factor (TNF) inhibitor or non-TNF biologic could be added. The records provided for review document that this patient has a diagnosis of rheumatoid arthritis. Treatment has included hydroxychloroquine, methotrexate and prednisone. The patients provider has recommended treatment with Xeljanz XR 11 mg tablets. Additional documentation submitted by the patients provider reported that the length of the patients treatment with methotrexate was more than three months. On the basis of the current documentation, treatment with Xeljanz XR 11 mg tablets is appropriate for this patient. Therefore, the requested Xeljanz XR 11 mg tablets are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of his behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients post-acute withdrawal symptoms were noted to be anxiety and agitation.  There was no evidence of danger to self or others.  There was no evidence of emotional, behavioral, cognitive, or impulsive symptoms that would impede recovery.  He was not manic or psychotic. He was anxious, but not on any psychotropic medications.  He was stable on Naltrexone and tolerating it well.  He was psychiatrically stable, and his hypertension did not require a residential setting.  He was motivated and completing his assignments. He was meeting with his chosen sponsor. His home environment was stable and supportive.  Based on the records, this patient no longer required 24 hour per day, seven day per week residential setting and could have stepped down to an ambulatory level of care. All told, residential treatment center services provided were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aubagio 14 mg tablets.Findings:  The physician reviewer found that : Aubagio is U.S. Food and Drug Administration (FDA) approved therapy for relapsing forms of multiple sclerosis, and it is typically used for early and mild forms of multiple sclerosis. The Health Plan has three formulary multiple sclerosis medication, all of which are injectable. In this specific case, since the patient has physical issues with being able to give herself an injection, an oral agent or intravenous agent would be indicated. Given the lack of options for using non-injectable agents, and this patients reported difficulty with self-injection, the requested Aubagio 14 mg tablets are medically necessary. 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 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: Overturned

A 21-year-old female enrollee has requested residential eating disorder treatment for the treatment of her eating disorder. Findings:  The physician reviewer found that this patients eating disorder was significant, both in terms of her preoccupation with body image (weighing herself twice a day) and frequency of binging and purging. She also has noted social impairment, having missed semesters in college due to the eating disorder.  As well, she continued to suffer from the eating disorder despite a prior 16 week IOP course.  As such, a more restrictive and therapeutically intensive approach would be the next step, one in which residential treatment would be indicated.  Overall, I find that there was medical indication for residential treatment and recommend reversing the Health Plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for the inpatient mental health services for treatment of the enrollee's behavioral health issues. Findings: The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on the CALOCUS, the patient remained at significant risk of harm (score 3) with a recent suicide attempt by overdosing on 500 mg of melatonin, but the notes stated that the patient denied any suicidal ideation during treatment. The patients functional status demonstrated moderate impairment (score 3) given the patients conflictual relationships with her parents and peers. The patient had moderate co-morbidity with OCD, trichotillomania, and depression (score 3). The patients recovery environment was moderately stressful (score 3) with transitioning to high school and limited peer support, and her parents were noted to be supportive (score 2). The patient had equivocal resiliency and response to treatment (score 3) considering the patients practice of non-suicidal self-injury behavior such as cutting to deal with stressors. The patients acceptance and engagement in treatment was constructive (score 2) since the patient was described as cooperative and compliant with treatment recommendations from her providers. This gives the patient a composite score of 19, which indicates the patient continued to require treatment for her OCD and trichotillomania, but she could be treated in a less restrictive environment such as an intensive outpatient program (IOP) or partial hospitalization program (PHP). However, although the patient could have been treated in a lower level of care, it is not standard of care to discharge a patient that requires IOP or PHP services without follow-up in place. Discharging the patient on a Sunday after admission on a Friday would not be proper care. Arranging outpatient follow-up during the weekend is not standard care as most PHP and IOP facilities are closed. Therefore, without proper follow-up in place, it would not have been safe to discharge the patient, and it was medically necessary to keep the patient at which time IOP or PHP could be arranged. Thus, the inpatient mental health services provided were medically necessary for treatment of this patients behavioral health issues but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira pen (adalimumab pen-injector kit 40 mg/0.8 mL). Researchers note that Humira is FDA approved for the treatment of hidradenitis suppurativa. Humira is the only FDA approved medication for this condition. Researchers concluded in their three-year study that continuous weekly dosing with Humira is a reasonable treatment option for long-term control of moderate-to-severe hidradenitis suppurativa.In this case, the patient has tried and failed treatment with rifampin, mupirocin ointment, clindamycin and Hibiclens. Despite these attempts at conservative treatment, the patients condition continues to worsen. There are no other reasonable, alternative treatment options available. Therefore, Humira pens are 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 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.