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 Humira.Findings: According to a study, the use of tumor necrosis factor (TNF) inhibitors in patients with psoriatic arthritis resulted in good responses and benefit from treatment. Moreover, disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, Arava, and sulfasalazine, are strictly contraindicated in patients who have a history of current use of alcohol. In this case, the patient has been diagnosed with psoriatic arthritis based on their symptoms of joint pain, swelling in multiple fingers, and x-ray evidence of erosive disease in the hands. Considering that they have an aggressive disease with signs of multiple joints involved, the patient would benefit from Humira. The submitted documentation reflects that the patient has a history of alcohol dependence and hepatotoxicity. Since this patient has elevated anti smooth muscle antibodies that could be indicative of additional pathology of the liver, the use of DMARDs is contraindicated and not recommended. Therefore, the requested Humira is medically necessary for the 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 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: Overturned

A 25-year-old female enrollee has requested coverage for inpatient care for treatment of her perforated appendix and appendiceal abscess. Findings:  The physician reviewer found that this emergent admission was necessary for treatment of the patients condition.it would not have been medically safe to transfer this patient to another facility prior to CT-guided drainage of the abscess.  This patient was in the early management stages of a critical status. A transfer would have placed the patient at an even higher risk. The emergency department nurse stated that the patient was stable to be transferred to the floor. This should not be construed to indicate that she would be stable enough to be transferred to another facility. The patient also would not have been considered stable after CT drainage.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her diabetes and obesity.  Findings:  Three physician reviewers found that on review of the relevant medical literature, it becomes clear that laparoscopic sleeve gastrectomy is an appropriate primary treatment of morbid obesity (as defined by a BMI of 40 or greater). The laparoscopic vertical sleeve gastrectomy is also recommended for the well selected patient by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery (ASMBS). Further, the studies have established the long-term safety, efficacy with the availability of 5-year follow-up data. Moreover, the American Medical Association has approved a CPT code for the procedure. Given the plethora of support for laparoscopic sleeve gastrectomy collected from various reliable sources, this patients surgery should be covered as it was likely to be more beneficial than any standard available therapy for treatment of her morbid obesity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz injections in the right knee and prospective authorization and coverage for a Supartz injection series in the right knee.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 options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the Supartz injections received in the right knee were medically necessary for treatment of the patients osteoarthritis of the right knee. Additionally, the requested future Supartz injection series in the right knee is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were and 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Orencia 125mg/ml Clickject, 4ml/28 days. Findings:  The physician reviewer found that American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, addition of biologic disease-modifying antirheumatic drugs (DMARDs) (Tumor necrosis factor (TNF) inhibitors such as Enbrel or Humira, Orencia, IL-6 receptor inhibitors and rituximab) or target synthetic DMARDs ( Janus kinase (JAK) inhibitors such as Xeljanz or Rinvoq) is recommended in persons with rheumatoid arthritis who have not adequately responded to initial conventional DMARD therapy to maximize improvement as quickly as possible. Furthermore, the guideline indicates that based on available data, there is no current recommendation for biologic DMARD versus a targeted synthetic DMARD when adjusting therapy to optimize disease control. The guideline does not specify that one drug class is preferred over the other at this time based on current available data. In this case, the patient has uncontrolled inflammatory arthritis secondary to rheumatoid arthritis and systemic lupus and has failed conventional DMARD therapy. According to the guidelines, the patient is a candidate for therapy with a biologic DMARD, such as Orencia, as the next line of treatment. Therefore, the Orencia therapy is appropriate. The guideline does not indicate that Enbrel, Humira, Xeljanz or Rinvoq must be utilized first prior to Orencia. The guideline indicates that one agent is not considered as preferential therapy over the other. Furthermore, Enbrel and Humira are associated with the development of drug-induced lupus and are therefore avoided in persons having systemic lupus erythematosus, as in the case of this patient. Thus, Orencia 125mg/ml Clickject, 4ml/28 days is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested mediation 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces. Another study analyzed 477 patient records to determine the percentage of patients with pressure ulcers/injuries (PU/Is) who required admission to a SNF for wound care. The authors found that the majority of patients with a PU/I required admission from home to a SNF for appropriate care. In this case, the records document that the patients spouse has been unable to provide adequate care for the patient as demonstrated by her falls, weakness, and  cachexia. The provider has recommended SNF placement to observe and assess the patients changing condition as well as evaluate and provide modified or additional services as needed. Although the patient was previously not considered appropriate for skilled care, her declining status, persistent wounds, and falls support an indication for 24-hour skilled care. Currently, the patient requires 24-hour care for monitoring, falls, wound care, and adequate nutrition. For these reasons, the requested SNF level of care is medically necessary for treatment of this patient. 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 family medicine, preventive medicine, and undersea and hyperbaric medicine, with expertise in wound care 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 54-year-old female enrollee, with breast cancer, has requested authorization for bilateral breast MRI.  Findings:  The physician reviewer found that an MRI can identify multi-focal and multi-centric disease and allow the surgeon to plan accordingly. Breast MRI is also appropriate to evaluate for breast cancer in the other breast according to the American Cancer Society. The American Cancer Society also advocates for breast MRI of the contralateral breast for newly diagnosed breast cancer patients. Further imaging of the patients breasts prior to additional breast surgery is imperative for her health and well-being.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for to see a pulmonologist for treatment of her chronic obstructive pulmonary disease. Findings:  The physician reviewer found that COPD is often a progressive disease, and even with optimal management, it is anticipated that a patient's lung function will worsen over time. Patients with COPD require frequent monitoring of symptoms and objective measurement of airflow limitation to determine when to adjust therapy and avoid complications. Treatment with a pulmonologist is consistent with the guidelines for the management of chronic obstructive pulmonary disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old female enrollee has requested for vertical sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Three physician reviewers found that there is insufficient data demonstrating that it is likely to be more efficacious than conventional surgical alternatives for patients such as this patient. In this case, the patient does not require a staged procedure based on her moderate BMI, and she has no significant co-morbidities. As such, conventional options such as LGB are medically appropriate in this setting. As noted by DeMaria and Jamal, LGB is an internationally supported procedure that is a reversible method for achieving significant weight loss. Fielding and Ren confirmed that mid-term results show LGB to live up to its early promise as an effective tool.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical artificial discectomy. Based on the available documentation, this patient has no symptoms or signs consistent with cervical radiculopathy or myelopathy. He has numbness of his hands and feet. However, despite these symptoms, the records do not include a physical examination of the hands or feet. Except for a supple neck examination, he has not had a complete neck examination. In addition, the records do not demonstrate that other sources of pain have been ruled out in the absence of documentation of Tinels examination, vascular examination, or electromyography with nerve conduction velocity (EMG/NCV) testing. He has not had any symptoms or signs to implicate the C5-6 or the C6-7 level, thus his pain generator has not been established. There is no report that he has functional limitations due to his cervical symptoms. Further, there is no report of at least six weeks of non-steroidal anti-inflammatory drug (NSAID) usage in therapeutic amounts, physical therapy, or a home exercise program. He has abnormal magnetic resonance imaging (MRI) and computed tomography (CT) findings at both levels, but there is no correlation with his history and physical examination. His neurological examinations have been grossly normal. Considering these findings, the patient does not meet the criteria for the requested surgical intervention. The criteria for cervical artificial discectomy requires documentation of intractable radiculopathy, cervical myelopathy, and persistent pain with functional limitations. Imaging must show nerve root compression at each level which corresponds to the patients history and physical examination, which is not present in this case. Furthermore, the patient has not failed at least six consecutive weeks of conservative management including NSAIDs, physical therapy, and a home exercise program. Thus, he fails to fulfill the criteria for artificial disc replacement. Accordingly, the requested cervical artificial discectomy is not medically necessary for treatment of this patients neck pain. Final Result: The reviewer determined that the requested surgery 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 neurological 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: Overturned

The patient is a 25-year-old female who has a left axillary mass that is painful when exercising. The mass had reportedly developed over a three-year period. The patient sought assistance from her general surgeon who suggested that a plastic surgeon remove the tissue. The plastic surgeon recommended removal of the tissue and sent a request for authorization for removal and tissue rearrangement. The authorization request was subsequently amended to a limited resection of breast tissue, bilateral. The Health Plan denied coverage for the procedure on the basis it is not medically necessary.The Health Plans denial should be overturned. Review of the clinical evidence indicates the patient has abnormal tissue that is symptomatic. The patient has been examined by appropriate specialists who have recommended an excisional biopsy. It is medically reasonable and appropriate to perform an excisional biopsy to relieve the patients symptoms. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old man with long-standing lumbar pain and multiple medical problems including heart disease, history of disc space infection, and diabetes. A recent neurosurgeon consultation has been obtained, which found surgery was not indicated. The patient believes surgery is the most appropriate treatment option for his condition; therefore, he has requested authorization and coverage for surgical intervention. The Health Plan has denied the request on the basis that surgical intervention is not medically indicated in this case.Upon review of the submitted clinical evidence, I agree with the neurosurgical evaluation and conclusion. The patient is not a surgical candidate. The patients orthopedic condition of degenerative arthritis with no evidence of neural compression or instability does not warrant surgery. Furthermore, even if surgery were indicated, it would be an extensive procedure, which is contraindicated in a patient with heart disease such as this patient. Moreover, the patient has been offered medically reasonable alternatives for treatment. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Botox injections for treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history of bruxism and migraines.  The records noted that at baseline there was constant daily pain in the head and jaw.  Botox treatments have been noted to result in subsiding of disabling headaches and muscle spasms, and the patients quality of life has been improved.  He has failed numerous prior treatments, including medications, physical therapy, oral appliances, and biofeedback.  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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary. An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening. Findings: Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  The patient has a family history of breast cancer with mother who was diagnosed at age 47 and a paternal aunt at age 78. The patient underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to a prior mammogram, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as being dense. The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, 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. In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three physician 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 reimbursement for reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that he patients provider noted in a letter that the patient has an elevated lipoprotein A level and a family history of cardiovascular disease and hyperlipidemia. Grundy and colleagues note that the main target of lipid lower therapy is low-density lipoprotein (LDL). While Reiter-Brennan and colleagues note that decisions regarding initiation of statin therapy are based on cardiovascular risk stratification, lipoprotein A testing is not generally part of evaluation. In this clinical setting,  current medical literature does not support the use of the service at issue over standard lipid panel studies. Therefore, the advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 and 3 are board certified in internal medicine with sub-specialty certifications in  cardiovascular disease, and clinical cardiac electrophysiology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic neck and shoulder pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.