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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia IV infusions. According to the American College of Rheumatology (ACR) guidelines, addition of a biologic disease-modifying anti-rheumatic drug (DMARD) or targeted synthetic DMARD is recommended for patients taking methotrexate who have not achieved rheumatoid arthritis disease control (Frankel, et al.). Furthermore, the ACR guideline indicates that switching to a biologic DMARD or targeted synthetic DMARD of a different class is recommended over a DMARD belonging to the same class for patients who have not been able to achieve disease control. In this case, the patient has a history of moderate-to-severe rheumatoid arthritis, which is evidenced by the large scale joint destruction she has experienced requiring bilateral ankle, hip, and knee surgery. In addition, the patients documented hand and foot joint deformities are consistent with aggressive rheumatoid arthritis. The patient reports 7/10 joint pain with more frequent rheumatoid disease flares. Prior treatment with typical conventional DMARDS including methotrexate, leflunomide, and Plaquenil, has failed to control the patients symptoms. Subsequently, the patient was placed on Enbrel. The patients provider has recommended treatment with Orencia, which is a biologic DMARD of a different class and different mechanism of action than Enbrel. Applying the ACR guideline recommendations, treatment with Orencia is supported as appropriate to manage this patients moderate-to-severe rheumatoid arthritis. All told, the requested Orencia IV infusions 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 internal medicine with subspecialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection performed Findings:  The physician reviewer found that the patient is  under evaluation and management for pelvic floor dysfunction.  the patient has constipation and significant straining with defecation.  This was evaluated with a dynamic magnetic resonance imaging (MRI) which suggested dysmotility and demonstrated mucosal prolapse with straining. Colonoscopy was unremarkable.  He achieved some benefit with anal manometry directed biofeedback.  A colonic transit study was normal.  The patient has requested reimbursement for Botox injection performed on 8/31/16.  Per the Health Plan, the services at issue were investigational for the treatment of this patient. This patient apparently is experiencing dyssynergic defecation. In patients with dyssynergic defecation, ineffective defecation is associated with a failure to relax, or inappropriate contraction of, the puborectalis and external anal sphincter muscles. This narrows the anorectal angle and increases the pressures of the anal canal so that evacuation is less effective.  Relaxation of these muscles involves cortical inhibition of the spinal reflex during defecation; thus, this pattern may represent a conscious or unconscious act.  The pathogenesis of dyssynergic defecation is not completely understood, but it is probably multifactorial.  It is thought to be an acquired, learned dysfunction rather than an organic or neurogenic disease.  Manometric diagnostic criteria for dyssynergic defecation include inappropriate contraction of the pelvic floor or less than 20 percent relaxation of basal resting sphincter pressure with adequate propulsive forces during attempted defecation.  Ultimately, treatment rests on biofeedback to retrain the pelvic musculature.  This is performed in a motility lab. Biofeedback is combined with laxatives, either osmotic or stimulant.  There is a lack of support for the services at issue in this clinical setting.  All told, Botox injection performed on the date of dispute was not likely to have been superior over other treatment options. 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 & 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are expert sin 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 48-year-old male enrollee has requested a single photon emission computed tomography (SPECT) scan for evaluation of his diagnosis with hepatitis B. Findings:  Three physician reviewers found that in this patients case, the services at issue were not likely to be superior over other available modalities.  There is a lack of support in the current medical literature for the services at issue in this clinical setting.  Current guidelines do not support the SPECT scan for the evaluation of this patient.  The records do not demonstrate that the SPECT scan would have changed medical management in this patient with liver disease.  Thus, the SPECT scan performed on the specified date was not likely to be of greater benefit than other alternatives for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female has requested coverage for radiofrequency ablation (radiofrequency neurolysis) of L5-S1 for treatment of her low back pain.  Findings:  Three physician reviewers found that the patient has chronic pain and is diagnosed with lumbar degenerative disc disease, a lumbar herniated disc and sacroiliitis. She has received a number of epidural steroid injections and sacroiliac joint injections with various results. Due to this patients sacroiliac pain, her provider wishes to perform radiofrequency ablation at L5-S1. This has been denied by the Health Plan as investigational, which is the subject of this review.This patient has a number of different diagnoses including sacroiliac pain. Although the patient has had some success with past spinal injections, the American Pain Societys clinical practice guidelines do not recommend radiofrequency ablation to treat sacroiliac pain (Chou, et al.). Additionally, there is a lack of peer-reviewed evidence supporting the safety and efficacy of radiofrequency ablation in the treatment of sacroiliac pain (Hansen, et al.). Thus, at this time, there is insufficient data from properly designed, randomized, double-blinded studies demonstrating that radiofrequency ablation is likely to be more efficacious in this setting than standard modalities. Therefore, the requested procedure is not likely to be more beneficial for treatment of this patients back pain than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewers found this technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for music therapy for treatment of the enrollees autism and obsessive compulsive disorder like symptoms. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature for the treatment of music therapy in this clinical setting. A single-center, parallel-group, randomized clinical trial of 30 patients with OCD who were randomly assigned to standard treatment (pharmacotherapy and cognitive-behavior therapy) plus 12 sessions of individual music therapy or standard treatment only for one month. The study found that music therapy resulted in a greater decrease in total obsessive score and was significantly more effective in reducing anxiety. The authors concluded that In patients with OCD, music therapy, as an adjunct to standard care, seems to be effective in reducing obsessions, as well as co-morbid anxiety and depressive symptoms. In addition, music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Therefore, music therapy is medically necessary for treatment of the patients ASD and OCD like symptoms. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services. The patient presented to urgent care for ankle pain. The patient described her pain as sharp, aching and constant for 2 days. There was no history of trauma. On exam, the patients vital signs were normal. The patient noted pain in the medial ankle, however, the exam was normal. Specifically, there was no tenderness to palpation, swelling, erythema or instability. There was normal range of motion and normal strength documented. X-rays were ordered and were normal. The patient was treated with an ACE wrap, and she was instructed to take over-the-counter Motrin, and to elevate and ice her ankle.The services at issue were not necessary for treatment of an emergency medical condition. An emergency medical condition is defined as a condition that manifests by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any body organ or part. In this case, non-traumatic ankle pain that has persisted for two days does not constitute circumstances under which the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any body organ or part. Non-traumatic ankle pain that has persisted for two days does not represent an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil 200 mg 45 tablets.Medical literature indicates that modafinil may be an effective alternative to stimulants in the treatment of hypersomnia in patients with bipolar disorder. A study conducted by Frye and colleagues concluded that adjunctive modafinil at doses of 100-200 mg a day may improve depressive symptoms in patients with bipolar disorder.In this case, the submitted medical records indicate that the patient has had hypersomnia for years. She is noted to have struggled with this condition and has seen many specialists in order to maximize her medication treatment for this condition. Medical recommendations include continuation of modafinil, and the literature supports use of the medication for bipolar disorder as well as hypersomnia. It appears that the patient has significant functional problems due to her hypersomnia as well as her bipolar disorder, as referenced by her use of the antipsychotic medication Seroquel, which was noted to cause sedation for the patient. It does not appear that she has had complete resolution of her hypersomnia with any treatment other than modafinil. The patients current use of modafinil appears to be working fairly well for her, and discontinuation could have significant adverse results. Under these circumstances, modafinil 200 mg 45 tablets 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 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

The father of an eight-year-old male enrollee has requested speech therapy for the treatment of her pervasive developmental disorder. Findings:  The physician reviewer found that this patient has been diagnosed with autism and a speech disorder.  Both of these are medically recognized and carry diagnostic codes.  As such, his medical problems are recognized and coded by the medical community.  Furthermore, the patients IQ falls into the very low normal range which would project him as capable of being educated.  Moreover, the patients speech therapy report indicates continued and steady improvement with his speech.  Each of these factors demonstrates that speech therapy is a medically appropriate intervention for this patient with a likelihood that it will improve his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee requested for a 12-week course of Sovaldi 400 mg and Olysio 150 mg for medical treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medications. According to the documentation submitted for review, there is a lack of evidence that shows the patient has significant fibrosis. In addition, the laboratory work-up and imaging suggests the patient has minimal disease. Thus, the benefit of treatment with respect to long-term outcomes in this clinical setting has not been established. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi 400 mg and Olysio 150 mg is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for subcutaneous immunoglobulin infusions, specifically, Hizentra. IgG subclass deficiency is defined as a reduction in one or more subclasses of IgG by more than two standard deviations below the mean for age-matched controls. This patient does not have evidence of an IgG1 subclass deficiency based on the available documentation. The patients IgG1 level on a earlier date was 368 mg/dL, with a reference range of 382-929 mg/dL, and on a later date, it was 337 mg/dL. These measurements are not more than two standard deviations below the mean for age-matched controls and do not support a diagnosis of IgG subclass deficiency. In addition, the records do not include an assessment of antibody function. Quantitation of IgG subclasses provides insufficient information about antibody function. Without clear deficits of functional antibody, IgG subclass deficiency is not likely to be clinically significant. Based on the available documentation, the requested subcutaneous immunoglobulin infusions, specifically, Hizentra, is 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for custom orthotics.Medical literature shows, Studies have shown that orthotics, both prefabricated and custom fitted, reduce pain and improve function in adults with acute plantar fasciitis with few risks or side effects. Used alone or in addition to conventional therapy (NSAIDs, stretching, lifestyle modification), orthotics are effective and well-tolerated by patients for short-term pain relief and improved function. Custom orthotics are utilized to control the abnormal biomechanics of a foot, thereby alleviating abnormal pressures that ultimately cause pain. In this case, the patient has severe over pronation, metatarsalgia, plantar fasciitis, and posterior tibial tendon insufficiency. The provider has recommended custom orthotics to help stop over pronation and allow for offloading of the plantar fascia and the metatarsals. There is sufficient support for the requested equipment in this clinical setting. Therefore, custom orthotics are medically necessary for treatment of 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 podiatrist 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for out-of-network mental health services on the basis the services were emergent. Review of the submitted documentation demonstrates a psychiatric evaluation was not performed upon admission. There was no risk assessment performed by a licensed professional; thus, an emergency medical screening or examination as required above was not performed. Further, patients who are experiencing a psychiatric emergency medical condition are considered an imminent danger to themselves or others. This can be due to a variety of factors including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. Per the submitted documentation, the patient was not experiencing any of these symptoms. The patients vital signs were stable. He was compliant with treatment. The physician note did not mention that the patient was an imminent danger to himself or others and required emergent hospitalization. All told, based upon the submitted documentation, the patient was not experiencing a psychiatric emergency medical condition.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.   Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone or any available standard modality.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.