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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Veltassa. Findings:  The physician reviewer found that per (FDA), Veltassa is approved for the treatment of patients with hyperkalemia. However, this patients records do not document failure, intolerance, or contraindication to sodium polystyrene sulfonate for the treatment of hyperkalemia. The sodium in sodium polystyrene sulfonate is not absorbed and has not been found to increase blood pressure levels in patients with hypertension. In addition, there is a lack of documentation that the patient has failed treatment with a low potassium diet prior to consideration for treatment with Veltassa. All told, the requested Veltassa 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 nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee requested a water circulating cold pad with pump (E0218), pad for water circulating heat unit (E0249), and the Smart-Sling (L3670) for medical treatment of her left shoulder bursitis, impingement, and acromioclavicular (AC) joint arthritis. Findings:  The physician reviewer found that based on the current medical literature, it was not medically necessary for this patent to receive passive water circulating cold pad with pump, water circulating heat unit as opposed to simpler applications of cold for post-operative shoulder care. Use of the Smart-Sling was likely to be beneficial given its design to assure some passive abduction, as well as versatility in allowing for beginning of range of motion in internal, external rotation at the discretion and supervision of the orthopedic surgeon. The abduction pillow is likely to help in decreasing tension at the surgical repair site, which is important during the healing phases post-surgically and will improve the likelihood of healing. All told, the use of the water circulating cold pad with pump (E0218) and pad for water circulating heat unit (E0249) were not medically necessary, but the Smart-Sling (L3670) was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Venclexta. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees acute myeloid leukemia (AML).Findings: Venclexta (venetoclax) is a BH3 mimetic drug that inhibits the function of the anti-apoptotic BCL2 protein. It is approved in chronic lymphocytic leukemia (CLL) that has TP53 deletion. It targets a new class of cancer causing proteins. Venetoclax has been tested in relapsed or refractory AML patients demonstrating safety and efficacy as a single agent. Furthermore, it has been combined with hypomethylating agents, decitabine and azacytidine, also demonstrating safety and responses in treatment naive AML patients. The combination has also been tested in the relapsed setting where patients had complete remissions from the combination. The records note the patient has exhausted standard AML treatment options but has a performance status and age amenable to allogeneic hematopoietic stem cell transplant, a curative approach. However, allogeneic hematopoietic stem cell transplant cannot be applied unless a complete remission is induced. Thus, based on the published data, decitabine in combination with venetoclax has been demonstrated as medically appropriate. As such, in this clinical setting, Venclexta has been demonstrated as medically necessary for treatment of this 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 medical oncology 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 52-year-old female has requested coverage for a consultation with a neurologist for treatment of her leg weakness, dystonia and stiff-person syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  This patient has had a progressive neurologic condition, with a variety of diagnoses entertained by different consultants.   There have been conflicting features, but significant evidence of autoimmunity.  She has been evaluated and treated at tertiary care centers, and she has requested an additional opinion by a community neurologist.  There is no evidence that a seventh opinion is needed. In this patients case, the clinical picture of autoimmunity with anti-GAD antibodies may still represent stiff-person syndrome. In this clinical situation, follow-up with one of the prior neurology consultants for re-evaluation is medically appropriate.  All told, the requested coverage for a consultation with a neurologist is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for a consultation with a reproductive endocrinologist for evaluation of the enrollees endometriosis. Findings:  The physician reviewer found that based on the available documentation, it is medically necessary for this patient to be evaluated and treated as considered appropriate by a reproductive endocrinologist. A reproductive endocrinologist is appropriate to advise the patient on the different management options available, especially if a future pregnancy may be desired. Given such considerations, having the patient seeing a reproductive endocrinologist at this point could be considered analogous to having a woman with complicated medical issues seeing a maternal fetal medicine specialist, for preconception counseling, prior to attempting to conceive. All told, the requested reproductive endocrinologist consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 reimbursement for the split night sleep study (procedure code 95811, polysomnography) and reimbursement and prospective authorization and coverage for the related continuous positive airway pressure (CPAP) supplies. The submitted documentation fails to demonstrate the medical necessity of the split night sleep study (procedure code 95811, polysomnography). In this patients case, the medical documentation noted a diagnosis of OSA dating back to 2008. A copy of the patients prior sleep test results were available and the medical records provided for review did not indicate why a repeat diagnostic sleep study was ordered for this patient. The medical records provided for review do not indicate that the patient had significant changes in her health that would have led to a change from her prior diagnosis of OSA. There was no indication of significant weight loss or an upper airway surgical procedure that would have been expected to ameliorate the patients sleep related breathing disorder. In this setting, there was no clear indication for the performance of repeat diagnostic sleep testing. Such testing would have otherwise been duplicative of services that were previously provided.However, the submitted documentation demonstrates the medical necessity of related continuous positive airway pressure (CPAP) supplies. In this patients case, the medical records noted a long-term history of CPAP use. It is usual and customary for CPAP accessories, to be replaced on a periodic basis. It is well established within current practice guidelines that CPAP supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. Replenishment is generally recommended for patients who have been compliant with therapy.  Per the records, this patient was noted to have continuously used her CPAP.Final Result: The reviewer determined that a portion of the services at issue and equipment at issue was and is 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 neurology with a sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for the genetic testing, Next Generation Sequencing (NGS) provided on 12/18/18, and prospective genetic testing, NGS, was and is likely to be more beneficial for evaluation of this patients multiple myeloma than any available standard therapy. Based on the documentation provided for review, Next Generation Sequencing (NGS) was used to monitor this patient with multiple myeloma for minimal residual disease (MRD). As noted by the International Myeloma Working Group (IMWG), monitoring for MRD in patients with multiple myeloma is considered within the current standard of care in evaluating a patients response to therapy. Moreover, the IMWG states that routine monitoring is oftentimes facilitated using NGS. Patients with MRD in the bone marrow after therapy at are higher risk for recurrence and may require additional therapy with closer monitoring. Accordingly, the genetic testing, NGS provided on 12/18/18, and prospective genetic testing, NGS, was and is likely to be more beneficial for evaluation of this patients multiple myeloma than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was and is 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:  One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and coverage for a CPAP device with accessories. The Health Plan denied the request and reported the equipment at issue was not and is not medically necessary for the treatment of this patient. At issue in this case is whether a CPAP device with accessories were and are medically necessary for treatment of the patients medical condition. Findings:  The physician reviewer found that suspicion of OSA triggers evaluation with a comprehensive sleep evaluation. Once the diagnosis is established, the treatment strategy includes CPAP, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. CPAP is the treatment of choice for mild, moderate, and severe OSA. The American College of Physicians recommend CPAP as initial therapy for patients diagnosed with OSA. The standard first-line OSA treatment involves CPAP devices, which deliver compressed air into the airway to keep it open. The benefits of CPAP based on meta-analyses include reduction in OSA severity, improvement in patient symptoms, particularly sleepiness, sleep-related quality of life, and reduction in blood pressure. In this case, the patient was diagnosed with OSA through a sleep study. Therefore, the CPAP device with accessories were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment was and 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 neurology 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: Medical Necessity
Decision: Overturned

The parent of a 9-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). The goals for older children are often to identify and remediate particular deficits, including non-compliance, verbal and non-verbal communication skills and self-help skills; such is the case with this patient. Therefore, it is medically necessary that the patient to receive ABA therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the abdomen for evaluation of the enrollees epigastric pain and chronic pain syndrome. Findings:  The physician reviewer found that the records provided for review document that this patient has a history of epigastric pain with prior surgery for hiatal hernia repair. Her abdominal pain is concerning as well as the declining hemoglobin and hematocrit levels. The persistent pain and dropping hemoglobin and hematocrit values in a patient with prior hiatal hernia repair require investigation and computed tomography (CT) scan is the most useful test for this indication. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 laboratory testing to re-evaluate the diagnosis of biotin synthetase deficiency (holocarboxylase synthetase gene) for evaluation of the enrollees diagnosis of carboxylase synthetase deficiency. Findings: The physician reviewer found that based on the records provided for review, the patients presentation is not consistent with carboxylase synthetase deficiency. Holocarboxylase synthetase would not present around nine years of age, as it would typically be symptomatic before three months of age without treatment. Biotinidase deficiency is similar and could be symptomatic after three months of age if not treated. However, both of these conditions are screened for in newborns. The treatment for biotinidase deficiency is about 10 mg of biotin per day while for multiple carboxylase deficiency it is higher. This patients symptoms are reported to respond to biotinidase treatment. Thus, enzyme testing may be appropriate, but there is no role for genetic testing in this clinical setting. Accordingly, the requested laboratory testing to re-evaluate the diagnosis of biotin synthetase deficiency (holocarboxylase synthetase gene) is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested testing is 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 sub-specialty certification in medical genetics 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 OxyContin 60 mg, Flexeril 10 mg, Percocet 10/325 and a referral to a spine surgeon for treatment of her back pain. Findings:  The physician reviewer found that the patient has inconsistent urine toxicology testing as well as unauthorized self-escalation of her opiate medications. She has violated the opiate maintenance agreement.  If patients repeatedly fail urine toxicology screening and self-escalate medication, then they are not acceptable candidates for opiate medications. The Centers for Disease Control and Prevention has specifically warned about the dangers of self-escalation and the mortality and morbidity associated with it. Thus, the requested OxyContin 60 mg, Flexeril 10 mg and Percocet 10/325 are not medically necessary for the treatment of this patient.  However, there is sufficient support for the requested referral to a spine surgeon in this clinical setting.  This patient has ongoing pain.  Further surgical evaluation is medically appropriate since she cannot be managed with medications effectively. Final Result: The reviewer determined that a portion of the requested medications and services is 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the patient was attending, participating and benefitting from the residential programming, which included family involvement, psychiatric services, individual therapy and an array of chemical dependency non-pharmacologic interventions.  Thus, the treatment was appropriate and reasonably expected to further the patients improvement at the time while minimizing the chance of relapse.  Further, the duration of treatment was well within community practice standards and facilitated a seamless transition to a sober living environment with community services and aftercare programming.  All told, continued residential treatment was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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

A 49-year-old female enrollee has requested a consultation with a bariatric surgeon for the treatment of her condition. Findings:  The physician reviewer found that this patient is an obese female with a body mass index of 39. She has failed multiple attempts at weight loss surgery. The patient meets nationally accepted criteria for consideration of weight reduction surgery. The requested consultation is medically indicated to help determine if surgery is an appropriate treatment modality for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 21-year-old female enrollee has requested for sonography, electromyography, evaluation of muscles and range of motion, and orthotic device for treatment of her dentinogenesis imperfecta. Findings:  Two physician reviewers found that dentinogenesis imperfecta is a genetic disorder, and this condition is responsible for the patients symptoms.  In this clinical setting, the requested orthotic device is likely to be more effective than other treatment modalities.  In order to alleviate this patients symptoms, the lost vertical dimension must be restored, as this is the cause of the discomfort.  This can be achieved with a removable intraoral orthotic device.  The superior efficacy of the remaining requested services, including sonography, electromyography, and evaluation of muscles and range of motion, has not been established in this patients case.