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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg/mL.Findings: A study indicates that, among the various risk factors of atherosclerosis, dyslipidemia plays the main role in the initiation and progression of the atherosclerotic process. Another study states, Clinicians have long used statin medications for the treatment of hypercholesterolemia, hyperlipoproteinemia, and hypertriglyceridemia as an adjunct to diet and exercise. The primary use of these agents is for the primary and secondary prevention of coronary artery disease. According to the study, Large phase 3 trials showed that both of the available medications in this class produce mean reductions in low-density lipoprotein (LDL) cholesterol of approximately 60% when added to standard statin treatment or when given alone, with a good safety profile. In addition to LDL reduction, the study indicates that Evolocumab (Repatha) also reduced lipoprotein (a) levels and improved those of other lipids in clinical studies. In this case, the patient was diagnosed with hypercholesterolemia. The patient successfully lowered his cholesterol after the initiation of Repatha. The medical literature supports the use of Repatha in this case. Therefore, the requested Repatha Sureclick 140 mg/mL is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested dual energy x-ray absorptiometry (DEXA) (peripheral bone mineral density measurement) and parathyroid planar imaging single photon emission computed tomography/computed tomography (SPECT/CT) scan for evaluation of the enrollees markedly elevated serum calcium and elevated parathyroid hormone. Findings: Two reviewers found that the parathyroid glands are small endocrine glands in the neck that produce parathyroid hormone in order to regulate blood calcium levels. Hyperparathyroidism results in excess production of parathyroid hormone, which may lead to numerous complications including weakness and fatigue, bone pain, muscle soreness, decreased appetite, nausea, kidney stones and osteoporosis. SPECT/CT fusion is a recent imaging technique that provides three dimensional functional imaging with advanced contrast resolution to greatly improve preoperative localization of parathyroid tumors (Kraeber-Bodere, et al). Because of the improved surgical outcomes following preoperative localization with SPECT/CT imaging, this study was likely to provide helpful data in this patients treatment. Similarly, the DEXA scan was an important part of this patients pre-operative work-up to determine whether the patient was already osteoporotic. Consistent with these findings, the DEXA (peripheral bone mineral density measurement) and parathyroid planar imaging SPECT/CT scan were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 48-year-old male enrollee requested a Walk Aide device for medical treatment of his familial spastic paraplegia.  Findings:  Three physician reviewers found that the Walk Aide device is a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways to mitigate foot drop during swing phase yet the same result can be accomplished using a standard passive AFO such as a molded thermoplastic device. An earlier small clinical trial in 2006 showed no significant functional improvement with a transcutaneous peroneal nerve stimulation device over a conventional ankle foot orthosis (Sheffler, et al). More recently, Everaert and colleagues showed equivalent functional gains from using Walk Aide versus conventional AFO devices. Bethoux and colleagues also concluded that use of the Walk Aide is equivalent to the AFO. Overall, there is no proven marginal benefit of using the Walk Aide orthosis while being worn over conventional AFO device in the setting of any neurological condition resulting in foot drop, including familial spastic paraplegia. There is a lack of current high grade evidence demonstrating that use of the Walk Aide effectuates sustained, significant strength or functional benefits while the orthosis is not being worn in the setting of any neurological condition resulting in foot drop. In summary, the Walk Aide is not supported as likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for onabotulinumtoxinA (Botox) injections. Based on the available documentation and current medical literature, the requested Botox injections are medically necessary for treatment of this patients medical condition. The patient is already taking Prozac as an antidepressant, which is a relative contraindication to the addition of amitriptyline, a tricyclic antidepressant. Topiramate has the potential to worsen her depressive symptoms. Botox is a potent muscle relaxant, which has been found to have analgesic effects in patients with a variety of pain syndromes. Data from clinical trials have confirmed the efficacy, safety, and tolerability of Botox in the prophylactic treatment of chronic migraine in adults. The U.S. Food and Drug Administration approved Botox for the treatment of chronic migraine in 2010. In addition, several studies have reported that Botox injections are also effective for chronic daily headache and migraine in children and adolescents (Ahmed, et al.; Kabbouche, et al.; Herd, et al.). This patient has failed treatment with acute abortive medications including sumatriptan and ibuprofen and has required multiple emergency room visits for migraine, receiving intravenous fluids and Toradol. Given the patients history of head trauma with concussive symptoms and the presence of chronic daily headache and chronic migraine, the requested Botox injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 47-year-old female enrollee has requested breast-specific gamma imaging. The Health Plan has denied this request indicating that for evaluation of her medical condition.   Findings:  Two physician reviewers found that there has been considerable debate concerning how best to evaluate a patient with dense breasts. Increased density of a womans breasts diminishes the sensitivity of routine screening mammography, and there has been considerable attention paid to the role of MRI in detecting breast cancer. The American Cancer Society currently recommends that MRI be utilized in high-risk patients. This is the path that was proscribed for this patient. There has been a change in her sequential MRI exams, though not sufficient to definitively warrant a biopsy. It is for this reason that BSGI was recommended. While BSGI is not routinely performed at most institutions, it does have a role in this particular patient. This patient falls into a high-risk category in that she has a sibling with breast cancer. BSGI has been shown to have clinical value in this setting.MRI is often cited as being highly sensitive, but not especially specific in detecting breast cancer. Brem and colleagues (2007) noted that MRI had a sensitivity of 100%, but a sensitivity of only 27%. This contrasts with a specificity of BSGI of 89%, but a sensitivity of 71%.  There are various reasons for this.  In a follow-up article from 2009, Brem and colleagues noted that BSGI has the highest sensitivity for the detection of invasive lobular carcinoma, and is an effective technique that should be used to evaluate patients with suspected cancer.Zhou and colleagues (2008) noted that BSGI has had a meaningful impact on multiple areas of breast cancer practice. The first is newly diagnosed patients with breast cancer to detect additional areas of malignancy. The second group (and this applies to this patient), are patients with BI-RADS 1, 2, or 3 with an abnormal physical examination, high risk, and/or dense breasts. The authors noted that BSGI was not affected by breast density and in that patient population it proved to be a useful adjunctive imaging study. Killelea and colleagues concurred, and noted that BSGI has a role as an adjunct imaging modality in younger women with dense breasts.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested an MRI of the lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The submitted medical documentation does not demonstrate the patient meets accepted clinical indications for an MRI of the lumbar spine. Detailed documentation of the patients medical history, physical exam, history of treatment, and working diagnoses has not been provided. Furthermore, there is no documentation that the patient has had a trial of any specific treatment prior to consideration of an MRI. Such trials of treatment would include a program of active physical therapy or therapeutic injections. In the absence of the evidence listed above, the MRI of the lumbar spine is not clinically indicated. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc intra-articular injections, weekly for three doses. The submitted documentation supports that the requested services are medically necessary. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, the requested Orthovisc intra-articular injections, weekly for 3 doses, are medically necessary to treat the patients medical condition at this time.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

The patient is a 31-year-old female who reports that she has high blood pressure and panic disorder. These issues are not documented in the submitted medical records. The patient wishes to have in-office general anesthesia for routine restorative dental treatment. The Health Plan has determined the use of general anesthesia is not medically necessary.The Health Plans denial should be upheld. Review of the submitted clinical documentation reveals no evidence of medical problems that would necessitate general anesthesia for dental treatment. Furthermore, there is no documentation that other options for treatment such as conscious sedation have been used without success. Therefore, I have determined the requested general anesthesia is not medically necessary to assist with the patients planned dental procedure. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mekinist (trametinib) 0.5 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Approximately 50 percent of cases of Erdheim-Chester disease (ECD) do not harbor a BRAF mutation, but will have NRAS, PIK3CA, or mutations of the RAS-PI3K-AKT signaling pathway, providing rationale for targeting other components of this pathway aside from BRAF. Treatment with a MEK inhibitor, such as Trametinib, is recommended for patients without a BRAF mutation and who have mutations that suggest a response to a MEK inhibitor, such as KRAS. In this case, testing has revealed that the patient has a KRAS mutation. Under these circumstances, where there is no standard of care for this rare disorder, and there is data to support the use of trametinib for a BRAF negative patient with ECD, Mekinist (trametinib) 0.5 mg tablets are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in medical oncology and hematology, 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 58-year-old male enrollee has requested Flomax for the treatment of his benign prostatic hypertrophy with obstructive symptoms. Findings:  The physician reviewer found that Flomax is a selective alpha-1 blocker that relaxes muscle tissues. The Health Plan formulary medications doxazosin, terazosin and prazosin are equally as effective as the requested medication Flomax. There is no documentation of treatment failure or significant side effect with the formulary medications. Thus, the Health Plans denial is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. The U.S. Food and Drug Administration (FDA) approves the use of Taltz (ixekizumab), a humanized interleukin-17A antagonist, for the treatment of adults with moderate to severe plaque psoriasis. Menter and colleagues noted that the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines on the management and treatment of psoriasis with biologics recommend ixekizumab as a monotherapy treatment option in adult patients with moderate to severe plaque psoriasis, without recommendations on step therapy. In this case, the patient has a diagnosis of chronic plaque psoriasis. Given that current medical literature supports the use of the Taltz in this clinical setting, the requested medication is medically indicated. Therefore, Taltz is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Linzess. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated in adults for treatment of constipation due to inflammatory bowel syndrome and chronic idiopathic constipation. The available records support that this patient has documented chronic idiopathic constipation. He meets the medical definition of constipation given his history of infrequent bowel movements, difficulty during defecation, or the sensation of incomplete bowel evacuation. The patient has already benefitted from and tolerated treatment with Linzess. He has documented failure to benefit from Amitiza, docusate, Senna, Ex-Lax, lactulose, and fiber supplementation. Accordingly, Linzess is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewer determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine sulfate CR 15 mg tablets. The Centers for Disease Control and Prevention (CDC) guidelines recommend providers avoid use of IR opioids in combination with extended-release/long-acting (ER/LA) opioids when possible. The guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In this case, the patient has been on chronic opioid therapy for non-cancer pain for many years. The patients provider documented that treatment with the requested morphine sulfate tab CR 15 mg is not supported by current guidelines. Further, the provider noted that the risk-to-benefit ratio was unfavorable to the patient by having two different doses of ER/LA opioid medications. The provider recommended IR morphine along with the morphine sulfate CR 30 mg tablet but did not endorse use of morphine sulfate CR 15 mg tablets. The CDC guidelines recommend against the use of ER/LA opioid formulations due higher risks of adverse outcomes. Moreover, the guidelines do not support use of two different ER/LA opioid formulation to be used concurrently along with an IR opioid. For these reasons, the morphine sulfate CR 15 mg tablets are 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 anesthesiology with subspecialty certification in pain management 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 53-year-old female enrollee has a laminoplasty to be performed along with a laminectomy for the treatment of her enlarging interdural lumbar tumor at this time. Findings:  The physician reviewer found that a laminoplasty may offer potential advantages over laminectomy. For example, posterior spinal elements are preserved with a laminoplasty and spinal stability can thereby (potentially) be better maintained. A laminoplasty is currently felt to be better-suited for young and active patients with mild-to-moderate central canal spinal stenosis in whom stability may be jeopardized by a standard laminectomy. The descriptions of the patient in the medical records indeed portray her to be relatively young and active. However, the clinical data give no indication that the patient has any degree of spinal stenosis, nor is there any data suggesting that the patient has any spinal stability issues. In fact, the most recent lumbar MRI specifically failed to reveal any evidence of spondylolisthesis. There is no compelling evidence that the patients condition necessitates a laminoplasty. A laminectomy is indeed the appropriate procedure for the patient given the absence of any evidence of spinal stenosis or impending spinal instability.