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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for gradient compression stockings. The records provided for review report a history of bilateral lower extremity weakness, pain, and intermittent swelling, as well as dizziness with standing, neck pain, and back pain. Magnetic resonance imaging (MRI) did not show any neural compression and repetitive stimulation studies on nerve conduction testing have been negative. Overall, the patients records do not provide adequate documentation of a medical condition for which compression stockings are indicated. Compression stockings are helpful for patients with conditions such as venous insufficiency conditions, lymphedema, congestive heart failure, and orthostatic hypotension (Tzani, et al.; Logan, et al.). In addition, compression stockings can play a role in preventing blood clots in patients who are severely immobile (Golemi, et al.). This patients physical examinations have revealed normal orthostatic vital signs and no evidence of leg swelling. The patient has symptoms of possible radiculitis or radiculopathy. However, compression stockings are not recommended for treatment of radiculitis or radiculopathy (Jensen, et al.; Lewis, et al.). The records do not support a diagnosis of myasthenia gravis since repetitive nerve stimulation tests have been negative and there are also no documented antibody test results consistent with myasthenia gravis. Based on the current medical literature and the records provided for review, the requested gradient compression stockings are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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: The patient has requested authorization and coverage for right sacroiliac joint injection with sedation (CPT 27096). Schmidt  and colleagues note that sacroiliac joint-based pain can be difficult to diagnose definitively through physical examination and conventional radiography, and that a fluoroscopically guided injection into the sacroiliac joint can be both diagnostic and therapeutic. The authors further note that the initial phase of treatment involves nonsurgical treatment such as activity modification, use of a sacroiliac belt, nonsteroidal anti-inflammatory drugs, and physical therapy. In this case, the patient has tried and failed conservative therapy. There is a history of one sacroiliac joint injection providing all day relief, and another injection that did not provide relief. Physical examination supports sacroiliac pathology with three positive tests. In this clinical setting, the requested service is medically indicated. Therefore, right sacroiliac joint injection with sedation (CPT 27096) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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

A 59-year-old female has requested Lipitor 20 mg one per day for treatment of her hyperlipidemia. Findings:  The physician reviewer found that based on the records provided, the patient has dyslipidemia that includes mild hypertriglyceridemia. Specific treatment for hypertriglyceridemia often is successfully accomplished with aggressive lifestyle modification including diet, weight loss, glucose control, and limiting alcohol consumption. Statin medications such as Lipitor or simvastatin are not first-line agents to treat hypertriglyceridemia. The National Cholesterol Education Program has specific recommendations for target LDL cholesterol levels, but not for target triglyceride levels since the association of hypertriglyceridemia and coronary artery disease is weak.  If medication is thought to be necessary to treat hypertriglyceridemia then niacin or fibrates are considered standard initial first-line therapy.  Moreover, there is no evidence of intolerance of the formulary statin at the current 20 mg dose and no indication that a higher dose of the formulary statin would not be tolerated or any less effective than Lipitor.  For the reasons discussed above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested neuropsychological testing for evaluation of his behavioral health condition.    Findings: The physician reviewer found that neuropsychological testing is indicated to evaluate conditions resulting from organic causes, such as traumatic brain injury, brain tumor, stroke or progressive neurological disorders. None of these are present in this patients case. In addition, the information that the referring psychiatrist was seeking could have been obtained through far less onerous evaluations. Specifically, the patient could have had psychological testing specifically to evaluate his attention, mood and anxiety for the purposes of establishing/confirming his psychiatric diagnoses. Such testing would most likely have been accomplished within a few hours and provided the psychiatrist with the information he needed on a timely basis. Secondly, in order to evaluate the patients communication needs, and especially given his history of previous speech therapy, a more appropriate referral for this concern would have been to a speech therapist. Such a specialist could have both evaluated the patient and initiated any treatment if it were deemed necessary. For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition.  Final Result:  The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male has requested a knee brace for treatment of his right knee injury.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the knee brace in this patients case.  The current medical evidence does not support the equipment at issue in this clinical setting.  An orthotic hinged brace is not indicated for a patient with a meniscal tear in the absence of any ligamentous instability.  Per the submitted medical records, this patients clinical examination revealed no instability or laxity to the ligamentous structures.  A hinged knee brace is unlikely to provide a positive effect in this setting.  All told, the knee brace was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for embryo biopsy. Chromosomal microarray (CMA), as used in this case, has become accepted as the first-line evaluation of multiple congenital anomalies in pregnancies via prenatal testing. CMA has also been shown to be effective in improving rates of successful pregnancy for patients with poor prognosis undergoing in vitro fertilization. One study showed a rate of implantation and clinical pregnancy of 63.2% after preimplantation genetic screening via CMA compared to 26.2% for patients who did not have CMA. CMA of embryo can reduce rates of multiple births, risks during pregnancy and premature births. As this patient has a history of a first trimester spontaneous miscarriage, two chemical pregnancies, and three unsuccessful intrauterine inseminations, CMA of embryo was indicated in this clinical setting. All told, the embryo biopsy was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 reimbursement and prospective authorization and coverage for a wearable cardiac defibrillator for treatment of the enrollee, who has a history of congestive heart failure.Findings:  The physician reviewer found that The physician reviewer found in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator, either wearable or implantable, before this time has not been demonstrated to improve outcome. For example, studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. Moreover, more recent retrospective trials in patients with newly diagnosed nonischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators.  At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explanation. All told, the wearable cardiac defibrillator from 2/14/17 forward was not and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the device at issue was not and 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 cardiovascular disease 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 the medication Krystexxa. A study noted that the current guidelines recommend having a uric acid level <6 ml/dL. In patients who have had reactions to allopurinol, If allopurinol toxicity does occur, alternative urate lowering treatments may be employed. As discussed in proposition 2, nonpharmacological approaches such as education, weight loss, reducing alcohol consumption, and dietary modification should always be considered. However, if urate lowering drugs are required, the current alternatives are other xanthine oxidase inhibitors or uricosuric agents. Several RCTs have shown that xanthine oxidase inhibitors other than allopurinol (for example, the metabolites of allopurinol, oxipurinol, tisopurine, and febuxostat) are effective in reducing SUA.81,82,83,84,85,86,87,88 However, their safety in patients who previously have developed AHP has not been established. Clinically, up to 40% of patients show cross reactivity between allopurinol and oxipurinol89,90; the nonpurine xanthine oxidase febuxostat is not reported to cause severe skin reactions and might be expected to have less cross reactivity than oxipurinol (though this has not been studied directly). Alternatively, as discussed in proposition 10, uricosuric agents may be considered. Although metabolites of allopurinol may be effective, there is up to a 40% chance of reaction due to cross-reactivity to allopurinol. A recent study demonstrated uric acid lowering in patients refractory or intolerant to allopurinol. Among patients with chronic gout, elevated serum uric acid level, and allopurinol intolerance or refractoriness, the use of pegloticase 8 mg either every 2 weeks or every 4 weeks for 6 months resulted in lower uric acid levels compared with placebo. Given the patients elevated uric acid, tophi and active arthritis, treatment is necessary. Given the risks of possible cross-reactivity with allopurinol and possible reaction to colchicine, the request for Krystexxa is medically necessary.Final Result: The reviewer determined that the requested medication Krystexxa 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

Findings:  The physician reviewer found that this enrollee has a history of rheumatoid arthritis. Previous therapy has included Arava and Remicade. Treatment with Remicade was stopped due to a lack of efficacy and because of side effects. The patient complained of pain, and physical examination identified proximal interphalangeal (PIP) joint swelling on the right and metacarpophalangeal (MCP) joint swelling on the left. The patient is noted to have been taking Xeljanz samples, which have been effective. The 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis (the 2015 ACR Guideline) recommends methotrexate (MTX) +/- Tumor Necrosis Factor inhibitor (TNFi) as the next treatment for patients who have failed MTX alone. The 2015 ACR Guideline states that there are potential longer-term safety concerns related to tofacitinib (Xeljanz) that need more study, partly related to the shorter experience using tofacitinib. Although the quality of evidence is low, the 2015 ACR Guideline recommends TNFi with or without MTX over tofacitinib. There are also multiple studies demonstrating efficacy and safety with TNFi in treating moderate to severe rheumatoid arthritis, and there is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or who have had adverse reactions to other TNFi. There are currently no studies looking at the failure of a first TNFi agent and a different biologic agent. Given safety data and efficacy rates, the 2015 ACR Guideline recommends a 2nd TNFi with or without MTX of non-TNF biologic agent over tofacitinib (Xeljanz). In this case, the patients medical records fail to demonstrate that he has had a failure of 2 TNFi, as recommended by the 2015 ACR Guideline. The patients records also fail to demonstrate a contraindication to a 2nd TNFi. Under these circumstances, Xeljanz XR 11 mg is not medically necessary for treatment of the patients medical condition.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 internal medicine, with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xarelto  for treatment of the enrollees deep vein thrombosis. Findings:  The physician reviewer found that in this circumstance anticoagulation is clinically indicated.  Initial anticoagulation can include subcutaneous low molecular weight heparin or fondaparinux and the data suggests similar efficacy with direct oral anticoagulants such as Xarelto. Longer term anticoagulation with warfarin is also of similar efficacy compared to that of oral factor inhibitors such as Xarelto. Given that the formulary alternatives available have similar efficacy, Xarelto has not been established as medically necessary for treatment of the 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 internal medicine with sub-specialty certification in cardiovascular disease 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

An enrollee has requested authorization and coverage for certolizumab (Cimzia) 400 mg every two weeks.Findings:  Two of three physician reviewers found that there is sufficient support for the requested medication in this clinical setting. The certolizumab level in the patient is below the threshold necessary for this drug to provide maximal efficacy. Well performed trials looking at the expected disease response based on drug levels demonstrate that a minimal drug level of approximately 30 should be pursued. The patient has significantly active Crohns Disease accounting for her symptoms. She has already failed two other biologics and has had extensive surgery. She has developed no antibodies to certolizumab. She is also pregnant, making certolizumab an ideal medication, as it is safe for her during pregnancy because it does not cross the placenta or get secreted during lactation. Accordingly, the medication certolizumab (Cimzia) 400 mg every two weeks is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Two of three reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in gastroenterology, 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: Upheld

A 63-year-old male enrollee has requested L5973 X1-microprocessor controlled feature, dorsiflexion and/or plantar flexion control includes power source and prosthetic device called an Endoskeletal ankle and foot system (coded as L5973)  for treatment of his status post knee amputation.  Findings:  The physician reviewer found that the requested device is not medically necessary for treatment of the patients medical condition. This patient has lung and peripheral vascular disease with chronic stump pain since an amputation. Multiple configurations of socket and feet have been tried to see if any combination can relieve stump pain and improve functioning. A trial of the Proprio Foot showed that the patient had reduced pain with it. However, it is not clear if his functioning improved. Moreover, he has had only a brief trial of the requested device which is not adequate to determine if it will ultimately reduce his pain and improve function when used regularly. Furthermore, the patient has shown to have poor psychological adjustment to his pain condition, which indicates his treatment is not a matter of prosthetic prescription but rather one requiring a multidisciplinary team to manage and cohesively address his psychological, emotional and medical needs. For these reasons the Proprio Foot has not been shown in his case to be a medically necessary device as there is insufficient evidence that demonstrates the Proprio Foot will improve his pain or function. For the reasons provided, the requested device is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a body mass index (BMI) of 38. The patients provider indicates the patient has comorbid conditions including diabetes, gastroesophageal reflux disease, and osteoarthritis. The patient has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates weight loss surgery is not medically necessary for treatment of the patients medical condition. Based upon the evidence provided, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. The severity of the patients comorbidities is not documented in the records provided. The most recent information regarding the patients medications indicates she has been taking Elavil, Protonix, Effexor, and hydrochlorothiazide. There is no mention of diabetes in the records provided. The patients lab values revealed a HemA1c of 5.5 and glucose of 113. Furthermore, the degree of reflux and presence of Barretts disease is unclear. With a BMI of 38, and without evidence of severe or intractable comorbidities, the patient does not meet medical necessity criteria for weight loss surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.