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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the WalkAide functional electrical stimulation device.Findings:  Three physician reviewers found The WalkAide device is a compensatory orthosis that triggers ankle dorsiflexion using peripheral neural pathways to mitigate foot drop during swing phase. The same result, however, is accomplished using a conventional passive ankle foot orthosis (AFO), such as a molded thermoplastic AFO.  In 2013, studies showed equivalent functional gains from using the WalkAide device versus conventional AFOs. Studies concluded that no statistically significant between-group differences were found for primary or secondary endpoints between the functional electrical stimulation-aided orthosis (WalkAide) and conventional AFO groups.  There is a lack of high-grade evidence supporting that the use of the type of device in question effectuates sustained, significant strength or functional benefits (i.e., while the orthosis is not being worn) in the setting of any neurological condition resulting in foot drop, including multiple sclerosis. The currently available literature does not demonstrate a marginal benefit of functional electrical stimulation devices, such as a WalkAide, over conventional AFOs in the setting of neurologically-based foot drop, such as the patients multiple sclerosis-related foot drop. While some risks related to pressure injury at contact points using a conventional thermoplastic AFO may be mitigated by a functional electrical stimulator-aided AFO, this risk mitigation does not come without other biomechanical costs and risks. There are, for instance, risks of decreased mediolateral stability with potentially increased instability during standing and the stance phase of gait, as well as issues related to the reliability and ease of use of the devices  and sustained electrode adherence/and or conductivity through the course of a day. This type of device may not be appropriate in the setting of lower limb weakness and spasticity that extends more proximally than the foot and ankle, such as that which occurs in the setting of multiple sclerosis. No net health or functional benefit of the requested device would be expected over a properly fitted conventional ankle foot orthosis for the patients condition. Thus, the requested WalkAide functional electrical stimulation device is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device 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 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary: The parents of an enrollee has requested authorization and coverage for Xeljanz.Findings: Three out of three physician reviewers found that Xeljanz is likely to be more beneficial for you than any available standard therapy.Available treatment options for alopecia areata are limited. This is especially true for diffuse/multifocal involvement, where standard therapies, such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and cyclosporine) are often unsatisfactory and associated with side effects. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors, such as tofacitinib, for alopecia areata. A study by Jabbari and colleagues demonstrated approximately 50% hair regrowth as measured by Severity of Alopecia Tool (SALT) scoring. Liu and colleagues performed a study involving patients age 18 years or older with alopecia areata with at least 40% scalp hair loss treated with tofacitinib. The authors found that 77% achieved a clinical response, and 58% of patients had an approximately 50% change in SALT score. Additionally, the medical literature reports that there have been minimal adverse effects reported to date. Moreover, these results are better than what has been reported for contact immunotherapy and systemic steroids, with intralesional steroid being impractical for larger areas of involvement. In conclusion, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in dermatology 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: Upheld

The patient is a 46-year-old female with a longstanding history of irritable bowel syndrome (IBS). Zelnorm has relieved her constipation, bloating, and abdominal pain. The patient has requested authorization for a longer duration of Zelnorm therapy. The Health Plan has denied the request on the basis that continuation of Zelnorm is not medically indicated.Although the duration of the patients use of Zelnorm has exceeded FDA guidelines, IBS and constipation are lifelong conditions. The patients provider has indicated that the patient has not responded to any conventional medications. In addition, it has been noted that the patients symptoms returned once Zelnorm was discontinued. In this particular case, given the patients clinical condition and her past success with Zelnorm, continued use of Zelnorm may be medically indicated. However, this determination cannot be made because the information submitted does not contain the necessary recent history to determine whether the patient is experiencing any of the known complications from the medicine such as syncope, diarrhea, or symptoms of ischemic colitis. Absent a sufficiently detailed history, the prolonged use of Zelnorm is contraindicated. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients provider submits documentation demonstrating the patient has no history consistent with known complications to Zelnorm, the Health Plans denial should be reconsidered because the patient has demonstrated a positive response to Zelnorm and no other medication previously tried was beneficial.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the RTC level of care services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom 6 continuous glucose monitoring system. The submitted documentation supports the medical necessity of the requested device. A continuous glucose monitoring system is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. The device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes.  Continuous glucose monitoring system have been shown to improve hemoglobin A1c levels of diabetic patients. This patient has been unable to optimize his glycemic control and is at risk of dangerous consequences due to his hypoglycemic unawareness. Therefore, the requested Dexcom 6 continuous glucose monitoring system is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with type 2 diabetes mellitus. Laboratory results indicated that the patients blood glucose level was 134 and the hemoglobin A1c level was 6.8%. It was noted the patient had been following a diabetic diet and had been taking metformin and glipizide. No polyuria, polydipsia, or significant weight changes were noted. The patient has requested coverage for a non-formulary exception for One Touch Verio Flex strips for glucose testing. The Health Plan denied the request and reported the requested equipment is not medically necessary for the evaluation of this patient. At issue in this case is whether non-formulary One Touch Verio Flex strips for glucose testing are medically necessary for the evaluation of the enrollees medical condition. The availability of accurate tools, including a meter and test strips, for self-monitoring of glucose levels allows the patient to stay on course with glucose fluctuations related to diet, physical activity and illness (ADA). In this case, the health plan has made available a different brand of meter and glucose test strips, Accu-Chek. The Accu-Chek brands, Aviva Plus and Smartview, are superior to the Lifescan's One Touch Verio and Ultra2 brands. The Diabetes Technology Society (DTS) Blood Glucose Monitor System (BGMS) Surveillance Program published a study that assessed the accuracy of 18 BGMS marketed in the U.S. across a wide range of blood glucose levels. The 18 BGMS represented approximately 90% of the commercially available systems that were used from 2013 to 2015 by diabetes patients. The Lifescan One Touch Verio passed two of three studies and did not receive a seal of approval from the DTS. The Accu-Chek Aviva and Smartview brands passed all studies and received the seal of approval from the DTS. The One Touch Verio brand was not superior to the Accu-Chek brand in a triple blinded study of 18 meters. Therefore, the requested non-formulary exception for One Touch Verio Flex strips for glucose testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in endocrinology 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: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested continued intensive psychotherapy for treatment of her mental health conditions. Findings:  The physician reviewer found that in this particular case, a summary was provided.  However, there were no progress notes, treatment plans, or patient-centric goals and quantifiable objectives submitted for review.  The status of other standard treatments, such as alternative levels of care, psychopharmacological management, community programming or other appropriate evidence-based psychotherapies, including interpersonal therapy, cognitive behavioral therapy or acceptance commitment therapy, is unknown.  Although the patient has unresolved intrapsychic conflicts, there is no acute psychiatric syndrome.  Based upon the documentation provided, continued intensive psychotherapy was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure 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 physician reviewers are board certified in diagnostic radiology 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 has requested authorization and coverage for Monovisc injection in the left knee. The Health Plan has denied the request as not medically necessary.A review of current literature pertaining to viscosupplementation reveals mixed results. Colleagues found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Colleagues performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 patients and concluded that the evidence did not show clinically important differences of HA over placebo. Colleagues concluded that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In light of the foregoing, viscosupplementation is recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, there is known benefit from prior injections, and the options are limited, with the alternative being a total knee arthroplasty. Therefore, the request for the Monovisc injection in the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment 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 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 representative of a 45-year-old male has requested admission to an acute rehabilitation facility that specializes in brain injuries for treatment of his medical condition status post brain aneurysm and intracerebral hemorrhage.   Findings:  The physician reviewer found that based on review of the available records, the patient has sustained a severe brain injury. His hospitalization with severe pneumonia in underscores the severity of his illness. The medical literature, including Eskildsen and colleagues review, discuss the indications for long-term acute care. Specifically, the authors noted that a patient needs to have an unstable condition with a need for multiple specialists providing frequent care. This patients medical condition currently is one of severe brain injury and chronic ventilator dependence. He is at high risk for recurrent pneumonia but does not have multiple organ dysfunction. In addition, he continues to have severe brain injury and ventilator dependence more than three months post-stroke. He is unable to make gains consistent with intense rehabilitation. He will need a protracted course with rehabilitation with small gains expected over a long period of time. The anticipated benefit from acute rehabilitation follows from progressive recovery from brain injury. The degree of this patients brain injury prohibits him from progressing with intensive therapy at this time. All told, the requested services are not supported as medically necessary in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture treatment. Researchers concluded that acupuncture is is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Currently, there is a paucity of peer-reviewed medical literature supporting acupuncture for the treatment of hand osteoarthritis. This patient reported that prior five acupuncture sessions were beneficial in reducing her symptoms. However, the records provided for review do not include documentation of specific measurable, progressive, objective functional improvement to support an indication for additional acupuncture. The continuation of acupuncture should only occur based on progressively greater objective gains. For these reasons, the requested acupuncture treatment is not medically necessary for 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 oriental 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: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of PsA but it is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA.  Additionally, the American College of Rheumatology does not have recommendations for the treatment of PsA.  Moreover, anti-tumor necrosis factor (TNF) agents have been proven to be effective for PsA, prevent progression of disease, and are thus the preferred agent for PsA. The current literature supports the use of conventional and anti-TNF agents over the use of targeted synthetic biologics such as Otezla for the treatment of PsA. In the medical literature, Haber and colleagues stated that, apremilast should be reserved for patients unable to take disease-modifying antirheumatic drugs. The records fail to demonstrate failure of FDA approved contraindication to bDMARDs. In this case, the patient has a history of PsA, palpitations and hypertension. The most recent evaluation fails to demonstrate active PsA or active psoriasis. While the patient reported muscle pain and bilateral lower extremity edema, there is no active synovitis on examination in either the large or small joints. She does have increased liver function testing, but the chronicity is unknown and it is unclear if the etiology has been further evaluated. The patient is noted to have a history of hypertension and palpitations but the submitted records fail to demonstrate a history of coronary artery disease, heart failure or arrhythmia. Hypertension and palpitations are not a contraindication to TNFi use. Moreover, the patient has no personal history of malignancy and the records provided do not establish that she is at an increased risk for malignancy. The current international guidelines recommend their use prior to Otezla due to their safety, efficacy and disease modifying affects. As such, the request for Otezla has not been demonstrated as medically necessary for treatment of this patients PsA. 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
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.