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

An enrollee has requested authorization and coverage for Actemra 162 mg / 0.9 ml syringe. Tocilizumab (Actemra) is noted to be useful in treatment of those patients with active rheumatoid arthritis who have not responded adequately to tumor necrosis factor (TNF) inhibitors. Tocilizumab is a non-TNF biologic. The 2015 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis indicates that if immunoglobulin (Ig) disease activity remains moderate or high despite diseasemodifying antirheumatic drug (DMARD) monotherapy, then the use of combination traditional DMARDs, the addition of a tumor necrosis factor inhibitor (TNFi), or the use of a non-TNF biologic or tofacitinib are recommended (all choices with or without methotrexate, in no particular order of preference), rather than continuation with DMARD monotherapy alone. In this case, the patient has active, moderate to severe rheumatoid arthritis. She has failed two different TNFi, methotrexate, Plaquenil and Orencia. Although the patient has not failed two preferred TNFi, the ACR guidelines do not recommend the trial of a third TNFi. The patient has also responded well to Actemra in the past. Under these circumstances, the requested medication Actemra 162 mg / 0.9 ml syringe is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested for robotic-assisted prostatectomy for treatment of his prostate cancer.   Findings:  Three physician reviewers found that using Robotic-Assisted devices (like the DaVinci) to perform prostatectomies has quickly become an effective and safe operation for prostate carcinoma. It is no longer an experimental or investigational procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural for treatment of the enrollee, who has a history of pain to his thoracic spine, lower back, testicular pain and bilateral legs, front and back.Findings:  The physician reviewer found that the submitted clinical documentation, the medical necessity of the requested lumbar/sacral transforaminal epidural has not been established. In this patients case, while the requesting provider noted that the patient went to physical therapy, in a telephone note instead of a regular office visit note, the physical therapy notation was not documented to be for any specific length of time and it is not corroborated with the medical records. This is part of the recommendation of having active exercise with the physical therapy. The literature does support that physical therapy, independent of an epidural, can give a patient lasting results. Moreover, the patient does not have any recent physical examination findings, electrodiagnostic or imaging studies supporting a diagnosis of lumbar radiculopathy involving the L5 nerve. Instead, the examination supports other diagnoses. Chronic testicular pain due to radiculopathy is noted to be usually at a higher level in the back than the L5 nerve. Furthermore, there are other treatment options as well as medications for low back pain, thought to be radicular, that have not been noted or performed. Final Result: The reviewer determined that the requested service 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 sub-specialty 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: Overturned

A 60-year-old male enrollee has requested for continued stay at a Rehabilitation Center for treatment of the enrollees medical condition. Findings:  The physician reviewer found that while the patients medical condition was becoming more stable, he continued to improve in his stair negotiation, so further improvement in a reasonable time was expected. The patient also demonstrated improvement in his activities of daily living.  Therefore, because the patient continued to benefit from skilled physical therapy at the skilled nursing facility, his continued stay was medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A forty-one year-old female with chronic daily headaches, fibromyalgia, and depression is requesting reimbursement and continued authorization and coverage of Lyrica.Reviewers Findings:  The reviewing physician found that Lyrica has not been well studied or proven effective for the management of chronic daily headaches, fibromyalgia or depression.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

The parent of a six-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that fever and severe head pain in a young child may be indicative of a wide range of maladies, from ear infection to sinusitis to life-threatening meningitis. It is often quite difficult for children to accurately communicate the location of pain. Further, parents should not be expected to interpret their childrens symptoms. A clinical assessment most often is required to identify the source of the pain. In this childs case, the parents took appropriate action. They administered a pain reliever and waited for effect. When no effect was evident, they contacted their health care provider for advice. They were instructed to seek medical attention for their child. Only upon physical examination was the source of pain identified as an ear infection. Given the nature and severity of the childs symptoms, it was reasonable and appropriate for the patients parents to seek evaluation at the closest emergency department.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for subacute residential treatment center (RTC) 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 including: (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. Per ASAM criteria, the patient met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services, such as RTC level of care. The patient required a safe and stable living environment in order to develop his recovery skills. Thus, the patient qualified for ASAM Level III treatment, such as RTC services. Given the severity of the patients illness, the subacute RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Upheld

A 51-year-old female enrollee has requested a bunionectomy  and surgical shoe for treatment of her hallux valgus deformity left foot.  Findings:  The physician reviewer found that based on review of the available records, the Academy of Ambulatory Foot and Ankle Surgery criteria for bunion surgery have not been met. Specifically, there is a lack of documentation that the patients bunion interferes with her ability to perform activities of daily living. Further, there is no documentation that her symptoms were not alleviated despite six months of conservative care including shoe gear modification, padding, inserts, injections, and medications. Moreover, the records do not indicate that patient meets the criteria of a bunion deformity with an intermetatarsal angle of greater than 15 degrees. Overall, the medical literature recommends that conservative treatment should be exhausted prior to consideration for surgery for this patients bunion condition. Therefore, the requested services are not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of an 11-year-old male enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that there is no evidence that the patient has failed a standard growth hormone therapy provocative test. In addition, there is no evidence that the patient has a pituitary abnormality. Furthermore, the patients bone age is and has been within normal limits. Moreover, extended growth hormone therapy carries the risk of accelerating epiphyseal plate closure and in fact making the patient shorter than he might have been. For all these reasons, there is no evidence to support growth hormone therapy for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment RT300 functional electrical stimulation (FES) therapy system.Findings:  The physician reviewer found that The records provided for review document that this patient sustained injuries in a motorcycle accident with incomplete spinal cord injury at the C5 level and traumatic sensory incomplete ASIA impairment scale grade B spinal cord injury at the L1 level. The patients provider recommended use of an RT300 FES therapy system, which provides passive exercise in patients with neurological weakness by using strategically placed electrical stimulation leads to activate weakened leg muscles to drive a stationary cycle. The current medical literature and clinical studies have not demonstrated that the device improves functional outcomes or neurological recovery in patients with spinal cord injury (Hofer and Schwab). Studies have not reported that use passive exercise with FES provides significant of health outcomes with respect to the cardiovascular, pulmonary, musculoskeletal or other organ systems (Ralston, et al.; Mayson and Harris). For these reasons, the requested durable medical equipment RT300 FES therapy system is not medically necessary for this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Urgent Care
Decision: Upheld

A 19-year-old female enrollee has requested an emergency room visit for the treatment of her right knee pain. Findings:  The physician reviewer found that the patient is a 19-year-old female who went to an emergency room for a dislocated knee. She was asymptomatic at the time of examination in the emergency department. She has had this chronic problem with the knee popping in and out. The evidence in the emergency department was that her problem, perhaps worse than usual, was nonetheless mild. There is no basis for determining that the problem was significantly worse than usual or constituted a medical emergency.  It would have been prudent to contact the on-call staff before going to the emergency room, given the chronic nature of her illness and the history of intermittent symptoms that spontaneously resolved.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee requested an additional weekly in-home occupational therapy session, in correlation with the weekly in-home applied behavioral analysis therapy sessions and weekly occupational therapy session currently being provided for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the patient has a diagnosis of autism spectrum disorder and presents with self-help deficits. Although the medical literature does support OT to be effective in improving the self-help skills of impaired children (Arbesman, et al), there is no indication the patient is homebound and thus requires OT services to be provided in the home. Orsmund and colleagues note that the development of self-help skills in autistic preadolescents are improved by social participation in group activities. Based upon the documentation provided, an additional hour of weekly OT therapy in the home setting is not clinically indicated. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan (Synvisc) injections - 2 units, in both knees. In the peer-reviewed medical literature, researchers concluded that hyaluronic acid as a pharmacologic intervention for knee osteoarthritis was superior to injected placebo or injected corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The study reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. This patient presents with severe bilateral knee pain that interferes with ambulation and activities of daily living. Clinical examination findings have been consistent with x-ray findings of moderate medial compartment narrowing and patella osteophytes. Enrollee has failed to improve despite physical therapy, activity modification, and corticosteroid injections. Overall, the evidence based medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Therefore, the requested hyaluronan (Synvisc) injections - 2 units, in both knees is medically necessary for treatment of this patients bilateral knee osteoarthritis. 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: Experimental/Investigational
Decision: Overturned

A 34-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her recurrent major depressive disorder (MDD). Findings:  Two physician reviewers found that the current scientific evidence has established TMS is a safe and efficacious treatment for patients with MDD (Janicak, et al). Additionally, TMS is being widely utilized in the clinical psychiatric practice at leading academic medical centers of psychiatry with documented success (OReardon, et al). This patient has failed to receive sufficient relief of symptoms from previous trials of multiple classes of anti-depressant medications. The providers notes report that the patient was previously treated with multiple psychopharmacologic medications without substantial relief of depressive symptoms or remission. The provider states the patient is currently in psychotherapy and has received cognitive therapy to help treat depression but despite these therapies, she continues to experience levels of depression. Thus, TMS treatment is a scientifically supported therapy for this patients MDD and is more likely to result in benefit to the patient than further trials of pharmacologic agents as many from diverse classes had been previously tried without significant improvement (George, et al). As such, use of TMS therapy has been established as likely to be more beneficial for this patients condition than any standard alternative treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 19.5 hours per week of applied behavioral analysis (ABA) therapy and 10 hours per month of supervision. for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA therapy is medically necessary for the treatment of children with autism spectrum disorder. One study indicated that intensive behavioral treatment is effective for children with autism. Another study found that children with autism receiving 25 hours per week of direct therapy were likely to have an optimal outcome than those receiving only 18 hours per week. In this case, the patient is already at the minimum level of ABA hours to achieve an optimal outcome. The records show that the patient has made progress with the maladaptive behaviors. However, he continues to have vocal and physical stereotypy at low level of 1.5 times per hour or less.  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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 64-year-old female has requested future scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral for evaluation of her vision while on hydroxychloroquine.  Findings:  Three physician reviewers found that the patient has been prescribed hydroxychloroquine for discoid lupus.  An examination one year ago showed visual acuity of 20/25 in both eyes. In this case, the patient has a condition requiring long-term use of hydroxychloroquine, and this could cause retinal damage.  Monitoring for toxicity includes yearly examination and ancillary testing such as automated macular visual field analysis, electroretinography, or optical coherence tomography.  The recommendations for this screening are well-established and accepted.  There is adequate support in the medical literature for the requested services in this patients case.  The use of the requested computerized ophthalmic diagnostic imaging is standard of care in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested X-Stop spinal surgery for the treatment of his back problems. Findings:  Three physician reviewers found that the X-Stop procedure is not the best procedure available for the described pathology in this patient.  Additionally, there is presently only short-term data on the safety and efficacy of the X-Stop device.  There is some concern for subsidence of the implant over time and loss of initial distracting effect on the osteoporotic spinous processes, and this patient would present significant concern for osteoporotic bone.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old woman with visual acuity of 20/40 in each eye. She is noted to have 2+ cortical cataracts and 1+ posterior subcapsular cataract (PSC) in the right eye. The patient states that she has difficulty driving and performing job-related duties due to her vision problems. Bilateral cataract surgery has been recommended. The Health Plan indicates that the submitted information does not demonstrate that cataract surgery is medically indicated.Although the patients stated visual acuity is 20/40, she has 2+ cortical cataracts and 1+ PSC in the right eye. These types of cataracts are known for causing much worse vision under certain lighting situations. Such patients generally perform very well when tested in a dark room; however, their vision is severely impaired in the sun or when encountering the glare of oncoming headlights. Such symptoms are well documented in the case of this patient. Thus, bilateral cataract surgery is medically indicated for treatment of the patients impaired vision.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that The National Comprehensive Cancer Network Guidelines for non-small lung cancer, version 1.2018 state that adequate tissue is needed for molecular testing. If there is no available tissue, plasma testing can be done such as Guardant360. In this case, there is adequate tissue as evidenced by the reading of the pathology report and the FoundationOne testing performed. BRAF, ALK, EGFR, MET, RET, ERBB2, PDL1, ROS-1 can be performed on tissue. The development of liquid DNA assays and their implementation into clinical practice is a valuable option in cases where tissue quantity is inadequate for mutation testing or in patients who refuse or are unable to undergo biopsy. The medical literature does not support the superior efficacy of this testing in this clinical setting. Accordingly, Guardant360 laboratory testing was not likely to have been more effective than the available options of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.