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 Xeljanz 5 mg twice per day for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that peer reviewed guidelines do not support the use of Xeljanz in rheumatoid arthritis without demonstration of failure from treatment with methotrexate and at least two anti-tumor necrosis factor agent (TNF) inhibitor biologic agents. In this patients case, there is no documentation of failure of two anti-TNF biologic agents. The Health Plans requirement that the patient try at least two anti-tumor necrosis factor agent (TNF) inhibitor biologic agents prior to treatment with Xeljanz is medically appropriate. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right hip arthroplasty. The submitted documentation supports the medical necessity of the requested procedure. The patient is documented to have sustained multiple traumatic injuries from a motor vehicle collision including a hip dislocation associated with fracture of the acetabulum. Traumatic hip dislocations are high energy injuries that often result in considerable morbidity. In patients with traumatic hip dislocation, many previously published cases show that arthroscopy reveals a broad spectrum of intra-articular damage which can be appropriately treated with arthroscopic intervention. CT is not sensitive in the detection of intra-articular osteochondral loose bodies or capsular interposition in all cases. Historically, open reduction has been the standard of care in hip dislocations that require surgical intervention. However, recent studies have documented the advantages of arthroscopic surgery in these cases. No serious periprocedural adverse events were reported with arthroscopy. Studies have confirmed the safety and efficacy of arthroscopic treatment of traumatic hip dislocations. In this case, there is a known fracture of the acetabulum with bone fragments in the joint. Under these circumstances, right hip arthroscopy is medically necessary for treatment of the patient's medical condition.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 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:  An enrollee has requested the services of an assistant surgeon during a knee arthroscopy for treatment of the enrollees right knee arthroscopy. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for services of an assistant surgeon during a knee arthroscopy has not been established. In this case, the patient was noted to have undergone a right knee arthroscopic synovectomy, resection of the medial synovial plica, pigmented villonodular synovitis, and complete meniscectomy. However, there is a lack of documentation supporting the medical necessity for an assistant surgeon over a surgical technician or a trained surgical registered nurse to assist with the procedure. In sum, there is a lack of rationale provided to support the medical necessity for an assistant surgeon over another health professional to act as a surgical assistant. For the reasons provided, services of an assistant surgeon during a knee arthroscopy were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A 41-year-old male enrollee has requested authorization and coverage for a computed tomography (CT) angiogram of the coronary arteries for evaluation of the enrollees chest tightness and irregular heartbeat.  Findings:  Two physician reviewers found that the patient has hypercholesterolemia and sought care from a cardiologist due to persistent and typical chest pain. He was evaluated in two years prior with a stress echocardiogram (ECHO), which was normal without evidence of myocardial ischemia. Due to persistent symptoms of angina, and to avoid an invasive coronary angiogram, a CT coronary angiogram was ordered to rule out obstructive coronary artery disease. The Health Plan ruled his coronary computed tomography angiogram (CTA) as investigational.  Coronary computed tomography (CTA) is a mature and accurate technology that is capable of imaging the coronary arteries and other cardiac structures in a completely non-invasive manner (Hendel, et al). No other non-invasive technology is capable of performing this feat with the clarity, speed and accuracy of CTA. In addition, coronary CTA has now been shown to have lower doses of radiation than other commonly used cardiac tests such as thallium and technetium nuclear stress tests, invasive coronary angiography, and percutaneous coronary angioplasty. Coronary CTA has been shown to provide not only excellent clinical performance potential but also relevant and incremental prognostic information (Mark, et al). The American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Society of Cardiovascular Computed Tomography (SCCT) guidelines recommend the use of coronary CTA in patients with chest pain and intermediate Framingham risk. This is due to the fact that coronary CTA is non-invasive and without complications associated with invasive coronary angiography. CTA also provides equal if not better information on the 3D geometry of coronary anatomy, coronary course in relation to other structures, plaque extent, plaque severity as well as plaque composition or morphology. This all translates into a robust technique which contains multiple important levels of clinical information in a safe, accurate and non-invasive manner. The guidelines for coronary CTA state that for the indication of a chest pain syndrome, with the explicit intent to rule out coronary artery anomalies, a score of 9 was assigned, suggesting this as an appropriate indication. In this patient, it is import to rule out congenital coronary anomalies as the cause of his persistent and recurrent chest pain. Per the ACC/AHA/SCCT guidelines, this is best accomplished with a coronary CTA. As such, the use of a coronary CTA angiogram in this case is medically appropriate and within the standard of care. Thus, the requested coronary CTA is likely to be more beneficial for evaluation of the patients suspected medical condition than any standard therapy (invasive coronary angiography).
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested chiropractic treatments for treatment of her back and neck pain. Findings:  The physician reviewer found that chiropractic treatments provided from the time frame specified and continuing chiropractic treatment was not and is not medically necessary. The treating chiropractic office notes lack the necessary clinical documentation to warrant the need for this kind of treatment. The chiropractic treatment notes for the services dates in issue indicate no change with a lack of documentation indicating improvement. According to American Chiropractic Association (ACA) guidelines, treatment should be terminated when there is no documented improvement with continuing treatment. The chiropractic treatment records show that over the last 10 treatments the patients overall pain has shown little to no change in improvement. Given that no improvement was documented for at least the last 10 visits, continued chiropractic treatments are not medically necessary. Based on the lack of clinical documentation of improvement and the above-cited chiropractic guidelines, the therapy at issue was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parents of an 18-year-old female enrollee have requested magnetoencephalography (MEG) and magnetic source imaging (MSI) for an evaluation of the enrollees focal epilepsy. Findings:  Two physician reviewers found that these tests remain investigational for evaluation of the patients condition. The patient has undergone a number of standard diagnostic procedures, which indicate that the seizure focus stems from the left frontal lobe. A large number of standard anti-epileptic drugs have not been effective and have produced intolerable and unwanted side effects. The patient is now a candidate for surgical resection of the lesion that is responsible for the seizures. A reliable and accepted technique for successful surgical ablation of the epileptic focus is the use of intraoperative corticography. The requested tests show promise as eventually becoming standard tests. However, further study is necessary to establish their reliability and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori (H. pylori) antibody blood testing. In the current peer-reviewed medical literature, researchers noted that H. pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. Researchers reported that a urea breath test or the stool antigen test can be used for non-invasive screening for H. pylori in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or retreatment. Further, researchers discussed that serologic testing is not recommended as the standard of care. Since the antibodies to H. pylori can remain elevated for a long time after treatment, evaluation with serologic testing has a greater potential for false-positive results. All told, the H. pylori antibody blood testing was not likely to have been more beneficial for evaluation of this patients symptoms than standard testing with stool antigen or urea breath assays. One reviewer found that the H. pylori antibody blood testing was likely to have been more beneficial for evaluation of this patients symptoms than standard testing with stool antigen or urea breath assays.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

A 25-year-old female enrollee has requested partial hospitalization program for treatment of her behavioral health condition.  Findings: The physician reviewer found that the partial hospitalization program (PHP) provided from the specified timeframe was not medically necessary for this patients medical condition. According to the American Psychiatric Association (APA), The psychiatrist should determine the least restrictive setting for treatment that would most likely address patients safety and promote improvement in patients condition. The optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. In this case, failure of previous treatments and worsening of symptoms was the rationale provided for the patients PHP level of care. However, there was no evidence that the patient posed an imminent risk to self or others or that her symptoms were likely to increase and result in deterioration or the need for hospitalization if not admitted to a PHP level of care. Moreover, the patients lack of response to prior treatments was likely due to her limited motivation for change. In addition, the patients documented lack of engagement and inconsistent attendance must be seen in the context of continued poor results. The clinical notes also show that the patient received dialectical behavior therapy (DBT) as well as a diagnostic assessment and medication management. The choice of Abilify as a new agent is strongly supported by the peer-reviewed literature. Olanzapine and aripiprazole are two agents that offer additional therapeutic effects on improving trait negative affectivity, disinhibition, psychotic symptoms, and interpersonal dysfunction (Ripoll). However, the addition and/or titration of Abilify could have occurred at a lower level of care such as an intensive outpatient program (IOP) allowing the patient up to three hours daily to continue with the acquisition of coping skills for her emotional dysregulation and effective monitoring of trial medications. Thus, the patient could have been treated at a lower level of care which could have reasonably been expected to improve the patients status and functionality. All told, the services at were not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested  for Nutropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the patients height is 17 cm below the average height for his age, and he has consistently been below the 1st percentile on the growth curve. His predicted final adult height is 160 cm, which is well below the normal height for a male.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Subutex for medical treatment of his chronic back pain.  Findings:  The physician reviewer found that the use of Subutex for chronic back pain is not supported in the medical literature. Given that this patient does not have an approved indication for treatment with Subutex, the records do not support the medical necessity of the requested medication for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested bariatric surgery for treatment of his morbid obesity.   Findings:  The physician reviewer found that With a weight of 435 pounds, a BMI of 75 and significant comorbid conditions, this young man would meet nationally accepted medical necessity criteria for consideration of weight loss surgery if he was an adult. His physicians indicate that all conservative efforts at weight loss have failed and they are in support of surgical intervention. Despite his age, it is highly likely that bariatric surgery will be beneficial for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Hyalgan injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the American Academy of Orthopedic Surgeons (AAOS) has changed their policy with regard to viscosupplementation and state that we cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. The medical literature concluded that treatment of knee osteoarthritis with injections of intra-articular hyaluronic acid does not meet CTAF criteria for safety, efficacy and improvement in health outcomes for progression to knee replacement or progression of disease. In addition, the medical literature reported that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. Based upon a review of the literature and AAOS guidelines, the requested Hyalgan injections are not medically necessary for treatment of this patients knee osteoarthritis.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 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. In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area appropriate to the treatment under review.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested Botox injections for the treatment of her pelvic pain and muscle spasms. Findings:  Two physician reviewers found that although trials using Botox are promising, there are no large, randomized, placebo-controlled trials determining that Botox is statistically significantly better than current therapies for current myofascial pelvic pain. In the absence of these evidence-based studies, the superiority of Botox in this setting remains unproven. Based upon the evidence available at this time, continued treatment with established therapies are likely to be more efficacious for this patient than Botox.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a two-month-old premature female whose gestation was complicated by polyhydramnios are requesting authorization of Synagis.  The patient was admitted to the neonatal intensive care unit and was intubated for increased work of breathing and hypoxia and received one dose of surfactant. The patient remained intubated for two days and continued on nasal cannula oxygen, the patient was then discharged with an apnea monitor.Reviewers FindingsThe reviewing physician found that the patients gestational age places the patient at risk for severe respiratory syncytial virus.  The patient also has the additional risk factors that increase both morbidity and mortality.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459).Findings: Two out of three physician reviewers found that Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459) is likely to be more beneficial for the enrollee than any available standard therapy.Liu and colleagues state, Small fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed SFPN attributed to autoimmunity received IVIG for more than three months. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. Further, Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The author notes, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has been diagnosed with small fiber neuropathy. Currently, there is no good standard of care to treat these patients. However, IVIG is the most frequently used treatment. According to medical literature, IVIG is safe and effective for SFPN patients with apparent autoimmune causality. Treatment with IVIG is indicated as there are no other good options to treat this patients condition. Therefore, Privigen immune globulin (IVIG), intravenous, nonlyophilized, 500 mg (HCPCS J1459) is likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in neurology. All reviewers 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 65-year-old male enrollee has requested an acellular xenograft (Oasis) for the treatment of his ankle wound. Findings:  Two physician reviewers found that there is no scientific clinical evidence to show the effectiveness of Oasis over standard care. While Oasis might be helpful, there is a lack of data to support its use over alternate standard treatments. The patient might benefit from additional hyperbaric oxygen therapy or a flap as recommended by his physician.