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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar. The patient reportedly has failed treatment with methotrexate, IVIG, Orencia, prednisone, azathioprine and CellCept.  Although there is literature to show possible efficacy of Acthar in refractory myositis, these studies are small.  There is a lack of randomized controlled trials demonstrating the efficacy of Acthar for the treatment of refractory myositis. The current literature supports the use of rituximab in such cases of resistant myositis. Rituximab has the most literature to support its efficacy and safety and is the preferred agent due to evidence demonstrating improvement in symptoms, reduction in dependence or oral steroids and safety. The medical records fail to demonstrate a trial of rituximab or a contraindication to it. As such, H.P. Acthar gel is not medically necessary.  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 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: Experimental/Investigational
Decision: Upheld

An enrollees parent has requested authorization and coverage for immunoassay for analyte other quantitative laboratory testing. This patient presents with a history of severe tree nut allergies and anaphylaxis. The patient was planned to undergo induction of food tolerance program. The two major recent practice parameters published by the National Institute of Allergy and Infectious Diseases (NIAID) and American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force do not support IgG food testing as a validated form of testing. Testing with IgG and IgG4 laboratory tests have shown equivocal outcomes with false-positive test results in non-food allergic patients. For these reasons, the immunoassay analyte quantitative laboratory testing was not likely to be more beneficial for evaluation 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 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 internal medicine with subspecialty certification in allergy and immunology 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: Overturned

An enrollee has requested authorization and coverage for the medication Taltz Autoinjector.Medical literature supports the use of the requested medication in this case. Taltz (ixekizumab) was approved by the U.S. Food and Drug Administration (FDA) in 2016 for the treatment of moderate-to-severe plaque psoriasis. Ixekizumab has been shown to be effective in the treatment of other types of psoriasis, including palmoplantar, erythrodermic, and generalized pustular psoriasis as well as nails affected by psoriasis. Ixekizumab is well tolerated by patients, with the most common adverse events being injection site reaction and infections such as nasopharyngitis and upper respiratory tract infections.In this case, the patient has extensive plaque psoriasis that has been reported to be non-responsive to first line medications. The patient has been using Taltz and has noted great improvement. Taltz (ixekizumab) represents a very promising therapy, providing an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect to psoriasis patients who previously failed or experienced an inadequate response to systemic therapies, such as this patient. Under these circumstances, Taltz Autoinjector, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested for psychological testing and a psychological diagnosis interview for evaluation of his depression and memory loss. Findings:  The physician reviewer found that psychological testing and evaluation in this setting can lead to clinically useful data that can affect treatment decisions as well as patient management.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findiings: The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), a low risk of harm. The patient did not have any suicidal or homicidal ideation. The patient has a functional status score of three (3), moderate impairment. The patients drinking impairs his ability to fulfill his responsibilities and obligations. The patients medical and psychiatric co-morbidity score is three (3), significant co-morbidity. The patients recovery environment score is one (1), low stress environment. The patient lives in an apartment with his spouse. He reports that their relationship is stable and his wife is supportive. The patients level of support score is two (2), supportive environment. The patients wife and friends are supportive of the patient and his desire for sobriety. The patient has a moderate response to treatment and recovery score of three (3). The patient obtained recovery during a structured setting in a RTC for 45 days. He has a history of relapse. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 16, which would meet criteria for treatment in a less restrictive environment such as outpatient treatment. Therefore, the IOP services provided were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG). Central to the idea of PANDAS is the concept that after Group A beta-hemolytic streptococcal (GABHS) infection, antibodies are generated that cross-react with antigens present in the basal ganglia and related structures. This in turn causes pathologic derangement of poly-synaptic pathways that subserve both cognitive, emotional and motor functions frequently associated with obsessive compulsive disorder and other neuropsychiatric disorders. In the medical literature, researchers reported on a clinical trial that showed no difference between IVIG and placebo in the blinded phase for pediatric patients with a purported diagnosis of PANDAS. All told, the current medical literature does not support the requested IVIG as medically necessary for treatment of this 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 pediatrics and neurology with special qualification in child 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: Upheld

A 45-year-old male enrollee has requested platelet rich plasma injections in both knees for treatment of his bilateral knee pain. Findings:  Three physician reviewers found that platelet rich plasma injections were not likely to be more beneficial to the treatment of the patients medical condition than any available standard therapy. The peer reviewed literature fails to indicate that platelet rich plasma injections are likely to be superior for the treatment of the patients medical condition than any other modalities. Metcalf and colleagues examined the current concepts around the basic science of platelet rich plasma (PRP) application, different preparation systems, and clinical application of PRP in disorders in the knee. The authors concluded that, In addition to the call for more randomized, controlled clinical studies to assess the clinical effect of PRP, at this point, it is necessary to investigate PRP product composition and eventually have the ability to tailor the therapeutic product for specific indications (Metcalf et al). Additionally, Braun and colleagues note, To date, 2 studies document the use of PRP for meniscal applications, but this field is largely unexplored. In sum, the services at issue were not likely to be more beneficial for the enrollees medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the autonomic nerve system function test for enrollee's suspected diagnosis of postural orthostatic tachycardia syndrome (POTS).  Findings:  Three physician reviewers found there is sufficient medical literature supporting the utility of autonomic nerve system function testing in this clinical setting. Although autonomic testing is not indicated for all patients, it does have select utility in patients suspected to have autonomic deficiencies and no clear cause for these symptoms, such as in this case. The patient had orthostasis and autonomic symptoms without a clear etiology and autonomic reflex testing was performed. In this case, the autonomic testing was able to provide a clear etiology. The diagnosis of POTS is critical to help guide clinical management and limit further testing. For the reasons provided, the autonomic nerve system function testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the testing 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 reviewers are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested general anesthesia for treatment of his dental condition. Findings: The physician reviewer found that studies have shown that adults with developmental disabilities can be safely managed under general anesthesia for dental treatment in an operating room/hospital setting with minimal morbidity and without extensive preoperative investigations. A study by Bader and colleagues looked at pediatric patients who received dental care under general anesthesia. The most common indication for general anesthesia is the patients inability to cooperate and undergo dental treatment under local anesthesia. Because dental restoration under general anesthesia does not require cooperation from the patient it is a very efficient treatment modality. It can usually be completed in one procedure. Similarly, general anesthesia for adults with developmental delay is generally considered to be a safe and effective practice. This patient presents with significant cognitive impairment and is unable to cooperate with and therefore unable to tolerate dental treatment in an office setting. The documented impression is of a chronic dental disorder requiring complete examination and treatment in an operating room. The patient has met accepted criteria for general anesthesia as outlined in the medical record. Use of in office conscious sedation is not feasible based on the medical needs of the patient. For these reasons, administration of general anesthesia is medically necessary and appropriate in this case.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients dental condition.  Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 Entyvio (vedolizumab) infusions in a hospital setting.According to the Entyvio prescribing information approved by the U.S. Food & Drug Administration, Infusion-related reactions and hypersensitivity reactions have been reported, including anaphylaxis, dyspnea, bronchospasm, urticaria, flushing, rashThese reactions may occur with the first or subsequent infusions of Entyvio and may vary in their time of onset from during infusion or up to several hours post-infusion. Additionally, the prescribing information states, Serious infusion-related reactions and hypersensitivity reactions including anaphylaxis have been reported following Entyvio administration in clinical trials, including anaphylaxis, requiring treatment with antihistamine and intravenous hydrocortisone. According to Yajnik and colleagues, treatment-related emergent adverse events resulting in hospitalization has been reported. Checkley and colleagues state that there is limited information in handling infusion reactions such as infusion-related anaphylaxis in alternate care settings without direct physician oversight. In this case, the patient has had biologic-related adverse reactions, and has had anaphylaxis in the past. Thus, Entyvio infusions in a hospital setting are medically necessary for the treatment of the 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 internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for intravenous immunoglobulin (IVIG) therapy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are many symptoms associated with postural tachycardia syndrome, including palpitations, syncope, paresthesias, lightheadedness, extreme fatigue and headache. Therapies include increased water/salt intake, elastic support hose, fludrocortisone, clonidine, propranolol, midodrine and pyridostigmine. Although there is some evidence to suggest that IVIG therapy can be effective in a select subset of patients with postural tachycardia syndrome, this is not considered standard therapy at this time. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested IVIG therapy is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

The patient has requested authorization and coverage for right shoulder surgery (CPT 29824 distal claviculectomy, CPT 29823 debridement and CPT 29826 coracoacromial ligament release). The request for distal claviculectomy is medically necessary for this patient based on the clinical and imaging evidence of severe acromioclavicular arthritis with impingement. The physician reviewer found that records document that the patient has been symptomatic for over one year. Some studies have shown that among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure (Pensak, et al.). With regard to the request for subacromial decompression, several studies present positive long-term results compared to conservative treatment in patients with isolated impingement syndrome (Lerch, et al.). The request for debridement will depend upon the operative findings and is likely to be medically necessary based upon the documented decreased range of motion, chronic pain, and rotator cuff tendinitis. All told, right shoulder surgery (CPT 29824 distal claviculectomy, CPT 29823 debridement and CPT 29826 coracoacromial ligament release) 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance use mental health residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines  recommend residential treatment for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and who  lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In this patients case, the records indicate that residential treatment was necessary to develop their recovery skills. The records document that detoxification was needed to stabilize this patient. Rehabilitation at the residential treatment level of care was medically indicated following detoxification to allow this patient to maintain sobriety and reduce their risk of relapse. All told, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for this patients condition. Therefore, substance use mental health residential treatment center services were medically necessary for the 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 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 Harvoni for treatment of his hepatitis C virus. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For treatment-naive or treatment-experienced patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy (Wong, et al; Kohler, et al). AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech and language delays.  Findings:  The physician reviewer found that educational programs generally provide autistic children with speech/language therapy as part of a comprehensive program. On-going goals for this patient can be appropriately addressed through an individualized education plan (IEP).