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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Nucala for treatment of the enrollees hypereosinophilic syndrome. Findings: Three physician reviewers found that Hypereosinophilic syndrome is a form of myeloproliferative disorder characterized by a vigorous proliferation of eosinophils that cause end organ damage through infiltration and chemokine/cytokine mediated mechanisms (Tefferi and Vardiman). Interleukin-5 (IL-5) is the main cytokine responsible for eosinophil proliferation. IL-5 is secreted by T cells. Thus, hypereosinophilic syndrome may be driven by expanded T cells, especially those of the Th2 phenotype as in atopic disorders (Zaheri, et al). Alternatively, hypereosinophilic syndrome may be caused by the cell intrinsic expansion of eosinophils through platelet derived growth factor receptor alpha (PDGFRA) and platelet derived growth factor receptor beta (PDGFRB) rearrangements (Gotlib and Cools). Hypereosinophilic syndrome may be amenable to Gleevac, which inhibits PDGF receptors or by interferon (Butterfield). Since this patient has progressed through common therapies including treatment with Gleevac, her provider has recommended treatment with Nucala, which is a monoclonal antibody against IL-5. Thus, Nucala is a reasonable therapeutic option for this patient whose disease has progressed on standard treatments and it is supported by the medical literature (Rothenberg, et al). All told, the peer-reviewed medical literature supports the requested Nucala as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested medication is likely to be more beneficial for treatment 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 internal medicine with sub-specialty certification in medical oncology 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

A 58-year-old female enrollee has requested a light therapy (ultraviolet B) system for home use for the treatment of her vitiligo and granuloma annulare. Findings: Three physician reviewers found that based upon the submitted documentation, the patient had not been treated with topical steroids or immunomodulators. She has recently been started on Plaquenil (hydroxychloroquine) and Humira. The patient has requested a light therapy (ultraviolet B) system for home use. The patient has been having in-office phototherapy appointments, but there is no documentation as to whether this is having any effect on repigmentation to determine whether the vitiligo is responding to ultraviolet light treatments. Based upon the submitted medical records, the patient has not failed typical first-line therapies, and there is no documentation that in-office phototherapy treatments are effective.  All told, the requested light therapy (ultraviolet B) system for home use is not likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old woman with chronic knee pain. The patient indicates she has been tried on Clinoril. The patient continues to have pain and therefore, has requested authorization for an MRI study. The Health Plan has denied authorization for the requested MRI indicating there is insufficient evidence the patient has been tried on conservative measures. The Health Plans denial should be upheld. The submitted documentation indicates the patient was examined by an orthopedist in August 2005. Results of this examination revealed no objective evidence of internal derangement. The examining provider did not find an MRI study of the patients knees is indicated. Based upon the information provided, there is insufficient evidence an MRI is medically warranted at this time. Therefore, I have determined the requested MRI is not medically necessary for evaluation 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 epidural steroid injections for treatment of his medical condition. Findings: The physician reviewer found that lumbar epidural steroid injection is a well-documented therapy for low back pain with radiculopathy, using steroid to help decrease inflammation along a nerve root facilitating improvement with pain and symptoms of radiculopathy. Manchikanti and colleagues evaluated the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain. The authors found that for lumbar disc herniation, the evidence is good for epidural steroid injections with local anesthetic and steroids. In this case, the patient has previously been treated with epidural steroid injections with reported relief. Based on the peer-reviewed literature and clinical documentation, epidural steroid injections are clinically indicated for 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 physician 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: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks (as requested) when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines.  In this case, the prior treatment history is not clearly documented, so the appropriate regimen cannot be determined.  However, it is clear that in the setting of NS5A resistance, 12 weeks of Zepatier requested would not be sufficient, as 16 weeks would be needed.  If the patient has been treated before, even this may not be sufficient. For these reasons, although treatment is needed regardless of fibrosis stage, Zepatier 50-100 mg tablets for 12 weeks is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the standing frame, E1399 Easy Stand Evolve E3 Medium frame for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewers found that the medical literature is inconclusive with respect to interventions such as standing frames to address health and functional issues in the setting of neurological disorders such as cerebral palsy. There is a lack of high-grade evidence to support the use of a passive standing device significantly improves health or functional outcomes. There is also a lack of scientific data in the peer-reviewed literature to support that standing frames provide other clinically significant benefits with respect to other health outcomes in the setting of these types of conditions.  Final Result: Two of three reviewers determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in physical medicine and rehabilitation 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

A 64-year-old female enrollee has requested Avastin (bevacizumab) and Camptosar (irinotecan) for the treatment of her glioblastoma multiforme. Findings:  The physician reviewer found that the data, though preliminary, is promising in support of this novel combination of medications for the treatment of glioblastoma multiforme. A trial of the proposed therapy is medically appropriate at this juncture. The patient is likely to either respond or show evidence of progression within a relatively short period of time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for durable medical equipment (DME) Wood-Cheneau-Rigo (WCR) custom thoracolumbar orthosis (TLSO) brace. Findings:  The physician reviewer found that the patient is a skeletally immature female who demonstrated a progression of scoliosis to a level that required intervention. The treatment of patients with adolescent idiopathic scoliosis is primarily limited to bracing and surgery. The use of bracing has been shown to slow or halt curve progression and may help avoid surgery. This patient was referred for a custom scoliosis brace that was fitted and reduced the patients curvature with use over several months. The current medical literature supports the use of custom bracing in the treatment of patients with adolescent idiopathic scoliosis to slow or prevent deformity progression and avoid surgical intervention (Weinstein, et al.; Minsk, et al.). Moreover, the specific type of brace provided in this patients case has been shown to be more effective than traditional custom bracing. Given these findings, the DME WCR custom TLSO brace was medically necessary for treatment of this patient. Final Result: The reviewer determined that the device at issue was 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: Upheld

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested authorization and coverage for Benlysta auto injectable. Benlysta is U.S. Food and Drug Administration (FDA) approved for the treatment of ANA or double stranded DNA positive Lupus. Per published medical literature, the precise profile of the SLE patient who would derive the most benefit from belimumab treatment remains to be defined. This patient is not documented to have positive ANA or double stranded DNA antibodies. The patient is receiving treatment with antivirals and her chest pain has not been diagnosed as pleurisy or pericarditis. There are no echocardiograms, electrocardiogram changes of pericarditis or chest films showing pleural effusions. Moreover, fibromyalgia can cause chest tenderness and pain. She has not failed two prior standard of care therapies despite failing Plaquenil. Overall, the patient does not meet the current literature based standard of care guidelines for treatment with Benlysta. Thus, the requested Benlysta auto injectable is not supported 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one-on-one counseling services once per week, or at any frequency for treatment of the enrollees post-traumatic stress disorder (PTSD) and mood disorder. Findings:  The physician reviewer found that the records provided for review document that this patient has been diagnosed with post-traumatic stress disorder (PTSD) and mood disorder. He has been experiencing psychological distress and psychotherapy treatment would be helpful in this case. However, there is a lack of rationale for individual one-on-one counseling services at least once per week. The Health Plan has authorized an out-of-Plan referral, which is appropriate for this patients current behavioral health needs. Thus, the requested one-on-one counseling services once per week, or at any frequency are not supported as medically necessary for treatment of this patients PTSD and mood disorder. 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 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 23-year-old female has requested for 10 to 20 more sessions of occupational therapy for treatment of her spastic quadriplegia.  Findings:  The physician reviewer found that occupational therapy is medically indicated when the requested therapy is an effective treatment for the patient's condition. The services must require the skills of a therapist or supervision of a therapist. In addition, there must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services are needed to establish a maintenance program.  In this patients case, the evaluation by her occupational therapist determined she had weakness of her right thumb and was unable to hold a cup. Following therapy, the patient did have a decrease in her spasticity and also demonstrated functional change regarding her ability to feed herself.  The requested occupational therapy sessions are indicated due to the objective functional loss from her distant occupational therapy evaluations and progress noted with her more recent therapy sessions.  All told, the requested 10 to 20 more sessions of occupational therapy are medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing.Findings:  Two of the three physician reviewers found that in this circumstance, guidelines for the management of coronary disease and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of treating coronary disease, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, particle sizing, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although the results of some of these specialized tests may be abnormal and considered independent risk markers for recurrent coronary events, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. According to current guidelines, high intensity statin medication is recommended with a goal LDL of less than 70 mg/dL regardless of results related to lipid particle sizing. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient.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 sub-specialty certification in cardiovascular disease 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

The enrollee is requesting authorization and coverage for budesonide (Pulmicort) Flexhaler, 180 mcg. The enrollee has a medical history of asthma. Her symptoms include shortness of breath, wheezing, and cough. Her symptoms can wake her up from sleep. A progress note indicated the enrollee was tolerating her medications well and her average pulmonary function test result was 340. The physician notes the enrollee is trying to get pregnant and Pulmicort is the best inhaler for pregnancy. Literature reports that, because most published human gestational safety data available are for budesonide, this drug is considered the preferred inhaled corticosteroid for the treatment of asthma during pregnancy. However, inhaled corticosteroids other than budesonide may be continued in enrollees who were well controlled by these agents prior to pregnancy, especially if switching drugs could jeopardize control of asthma. Based on the enrollees stated intention to become pregnant, budesonide (Pulmicort) Flexhaler is the inhaled corticosteroid medication of choice.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female has requested coverage for gastric bypass surgery or consultation for treatment of her obesity, high blood pressure, sleep apnea, and knee and low back pain.  Findings:  The physician reviewer found that while there is conflicting information in the records provided pertaining to the patients height, regardless of the height utilized, clinically severe or morbid obesity is not documented at this time as the patients BMI is less than 35, with her most recent medically documented weight of 199 pounds. Medical notes explaining the height discrepancy, as well as verification of the patients new self-reported weight of 212 pounds needs to be documented. Bariatric surgery for low BMI is currently undergoing evaluation in clinical trials; at this time, it is not considered standard of care. The results of these clinical trials have not yet been published. In sum, the efficacy of bariatric surgery for patients with BMIs below 35 has not been documented in the peer-reviewed medical literature. There is no medical reason for the patient to undergo a bariatric surgery evaluation at this time, as she does not meet the qualifications for bariatric surgery.