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

The patient is a 57-year-old female stated to have ankylosing spondylitis, HLA-B27 negative. She was treated with Enbrel for a period of three months, but this was stopped because of intolerance manifested as increasing rash. Her current condition is described in an office visit note from November 2005 as demonstrating synovitis of wrists, base of thumbsknees have mild crepitation and possible popliteal cystsmtps have possible synovitis, and the description of axial range of motion suggests modest limitation.At issue is whether Humira is medically necessary for treatment of the patients medical condition.The patient has been diagnosed with ankylosing spondylitis. The available records are not clear as to whether the patient has mostly peripheral involvement, or whether non-biologic DMARDs have been tried and if so, what results ensued. However, the patient was already deemed by the Health Plan as appropriate for treatment with a TNF inhibitor, and a trial of Enbrel had to be stopped because of rash. Thus, there is an acknowledged need for a TNF inhibitor for this patient, and the failure of Enbrel due to side effects would not eliminate that need. As such, the patient is an appropriate candidate for treatment with another TNF inhibitor.Standard rheumatologic practice in patients with inadequately controlled ankylosing spondylitis despite treatment with non-biologic DMARDs includes the use of TNF inhibitors. Clearly, all three available agents (Enbrel, Remicade and Humira) are very effective in the treatment of ankylosing spondylitis, and all three have been used by rheumatologists in this context. Since the patient has been deemed an appropriate candidate for TNF inhibition to treat her ankylosing spondylitis, and has already failed Enbrel due to side effects, the use of Humira is medically reasonable and appropriate for treatment of her condition.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested occupational therapy for treatment of the enrollees delays in skill development in the areas of fine motor grasping skills, visual motor/visual perceptual skills and activity of daily life (ADL) skills. Findings:  The physician reviewer found that  occupational therapy techniques include sensory integration techniques. Sensory integration therapy was introduced many years ago, on the assumption that behaviors could be modified by alteration of the established sensory developmental patterns that were in place. The article by Lane and Schaaf found supporting evidence that behaviors can be modified by sensory input. Moreover, the studies by Miller and colleagues support the efficacy of sensory modulation. For the reasons given above, the requested occupational therapy is medically appropriate and necessary for this patient.
Appeal type: Urgent Care
Decision: Upheld

A parent of a six-year-old male enrollee has requested  emergency services for treatment of the enrollees right earache, cough and nasal congestion.  Findings:  The physician reviewer found that the submitted documentation indicates the patient had an acute ear infection. According to the emergency department records, the patients pain was moderate in nature (6 on a scale of 1 to 10). There is no documentation of other presenting symptoms that could have reasonably been expected to result in any serious jeopardy to the patients health or bodily functions. All told, the patients symptoms were not of sufficient severity on the date in question to cause a prudent layperson to reasonably believe that immediate medical evaluation in an emergency department was required.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repair of her wheelchair. Findings:  The physician reviewer found that this patient has spina bifida, and she requires a manual wheelchair for all aspects of basic mobility and social/community integration. Her ultralight manual wheelchair frame is damaged. Her wheelchair is more than seven years old. Repairing a damaged frame on an ultralight manual wheelchair that is more than seven years old is not reasonable, as the repaired wheelchair would not be expected to last very long, if it can even be fully repaired to provide full propulsion efficiency. Therefore, the requested repair of the patients wheelchair is not medically necessary.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 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: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollees delusions and hallucinations. Findings:  The physician reviewer found that based on the available documentation, the services could not have reasonably been delivered effectively at a less restrictive setting. The patient had a serious underlying formal thought disorder as evidenced by her hospitalization two months prior and complicated by her substance use, non-adherence with medications, and lack of family support. The patient was guarded, suspicious and delusional. The patient was deemed to be gravely disabled due to an inability to provide self-care secondary to her psychosis. The patient required antipsychotic medication for her agitation and three days later she was described as more disorganized. A conservatorship was approved and the patient was started on a long-acting injectable antipsychotic medication. An additional oral antipsychotic medication was added due to her persistent psychotic burden and delusional thought process. The patient was paranoid and hallucinating. The patient was agitated and disorganized and her delusions were more prominent. The patient believed that people could read her mind and she threw a chair at another person which prompted emergency treatment with an antipsychotic and benzodiazepine. Her oral antipsychotic was increased that day as well. The patient was less agitated with no aggressiveness. In sum, the inpatient stay more than likely prevented undue morbidity, unnecessary risk to the community and prompt re-admission to the hospital. Considering the severity of her illness burden, retaining this patient in the inpatient setting until the establishment of conservatorship and formalization of aftercare planning was appropriate. Further, the acute inpatient setting remained safe, appropriate, consistent with good medical practice in the U.S., and is reasonably expected to both improve the patients condition and prevent a more serious episode of illness. Overall, the patient should be afforded the opportunity to stabilize and consolidate the treatment gains before transitioning to an appropriate, less restrictive treatment setting. 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 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 positron emission tomography (PET) scan with computed tomography (CT) for attenuation for evaluation of the enrollees neuroendocrine tumor. Findings:  The physician reviewer found that Neuroendocrine tumors develop in hormone-producing cells of the bodys neuroendocrine system, and are located in organs such as the stomach, intestines, pancreas, and lungs. Neuroendocrine tumors have receptors for somatostatin, a hormone that regulates the endocrine system. Gallium 68-dotatate is a positron emitting analogue of somatostatin. The uptake of gallium 68-dotatate reflects the level of somatostatin receptor density in neuroendocrine tumors. As such, it can be used to guide diagnosis, staging, and treatment management. Current studies have demonstrated that it be used in patients with prior diagnosis and not in patients presenting with symptoms alone as the diagnosis rate in this scenario is 1%. The standard modality is using the In-pentetreotide scan. A study was performed which demonstrated that of 78 patients who underwent ln-pentetreotide scan and a PET with gallium 68-dotatate, changed care in 28 patients, with a major change for 19 patients because additional metastatic disease was detected. This study reported that ln-pentetreotide lacked uniform quality and exposed patients to a higher level of radiation. The National Comprehensive Cancer Network (NCCN) guidelines recommend that a somatostatin analog based imaging study be performed at the time of initial diagnosis and re-staging or evaluation of tumor burden. Given that the PET scan with gallium 68-dotatate has been demonstrated to be superior in diagnosing and staging neuroendocrine cancers, the request for PET scan with CT for attenuation has been established medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for Coflex surgery. In the peer-reviewed medical literature, Zhang and colleagues reported on 78 patients with degenerative lumbar spinal stenosis that were divided into control and observation groups. The control group was treated with traditional decompression and fusion and the observation group received dynamic fixation with the Coflex system. The authors found that surgery and hospitalization were shorter in the observation group than in the control group with less intraoperative blood loss with improvement in the postoperative functional scores as well as rapid rehabilitation and lowered incidence of adjacent segment degeneration when compared to the control group. Further, Li and colleagues noted that Coflex was safe, effective, and beneficial compared to decompression and fusion for lumbar spinal stenosis. As such, the requested laminectomy and use of Coflex dynamic fixation is appropriate in this patients case. Thus, the requested Coflex surgery is likely to be more beneficial than any available standard treatment for this patients medical condition. One reviewer found that the requested Coflex surgery is not likely to be more beneficial than any available standard treatment for this patients medical condition.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for the use of non-emergent transportation to and from medical appointments for treatment of his condition. Findings:  The physician reviewer found that this need can be met by taking frequent breaks while driving, or he can recline in a private vehicle being transported by someone else. There is no documentation that the patient has any unusual anatomy or skin breakdown such that he cannot be positioned in a private vehicle.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-nine year-old female who was diagnosed with left sided breast cancer is requesting coverage for the Oncotype DX assay.Reviewers Findings:The reviewing physician found that this test has been shown to be clinically useful and assisted the physician in the care and management of the patient.  The reviewing physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) administration of the Remicade infusion at a hospital-based outpatient infusion center provided by Childrens Hospital and Research Center at Oakland, and (2) administration of Remicade infusions at a hospital-based outpatient infusion center for one year. Reporters note that infliximab infusions are a common treatment for children and adolescents with inflammatory bowel disease, and infusions have traditionally been provided at hospital-based infusion centers. The authors further note that in conducting a quality improvement approach to increase the number of external infliximab infusions, 40% of patients were considered by their providers to be poor candidates for external infusions due to considerations such as poor prior infusion reactions or significant psychosocial concerns. In this case, the patient has Crohns disease and had responded to treatment with infliximab, with normalization of inflammatory markers despite persistent anemia and recurrence of symptoms. The documentation reflects challenges with vascular access, due to both the patients anxiety and challenging IV access. Given these challenges, this patient is not an appropriate candidate for non-hospital-based infusions, and the requested services are medically indicated in this clinical setting. Therefore, (1) administration of the Remicade infusion at a hospital-based outpatient infusion center provided by Childrens Hospital and Research Center at Oakland, and (2) administration of Remicade infusions at a hospital-based outpatient infusion center for one year was and is medically necessary for the 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 pediatrics with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested coverage for flexion and/or extension DynaSplint low load prolonged duration stretch (LLPS) devices. The Health Plan has denied this request indicating that the device at issue was and is considered investigational for treatment of the enrollees hallux valgus deformity.  Findings:  Two physician reviewers found that The patient underwent a bunionectomy with screw fixation and subsequently underwent the removal of painful hardware. Following removal of the hardware, the patient had painful and limited range of motion (ROM) and home physical therapy (PT) as well as traditional office based PT, was provided. At 8 week follow-up, the patient presented with continuous pain and lack of appropriate mobility. A DynaSplint was prescribed. The patient has used the device with further improvement. The patients request for coverage for the DynaSplint was denied by the Health Plan as investigational for treatment of the patients medical condition. The literature shows that the use of DynaSplint at multiple different joint structures is highly effective, however its use has not been thoroughly established for the foot. There are limited case series and reports demonstrating that DynaSplint does provide improved ROM when used for the foot (Curran and Willis). It is thus reasonable and prudent to expect that the DynaSplint can materially aid this patient in her return to normal function and should therefore be approved (McClure, et al).
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested for participation in a clinical trial entitled A Phase I Open-label Dose Finding Study Evaluating the Safety and Pharmacokinetics of AMG 479 in Subjects with Advanced Solid Tumors for treatment of his desmoplastic small round blue-cell tumor.  Findings:  The physician reviewer found that AMG 479 is an investigational drug currently undergoing Phase I trials. Such trials essentially focus on dosage and toxicity and offer little discernable benefit to the patients being treated. Thus far the only published data on this drug (including 2007 ASCO) relate to such Phase I trials. There is no meaningful data about its efficacy. AMG 479 is of no proven clinical benefit in this or any type of cancer, as yet.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine. In this case, the patient underwent a routine screening colonoscopy. She did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. The patient was not morbidly obese. Although the patient reported a history of pain with colonoscopy which resulted in the procedure being discontinued, there was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 2. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the services at issue were not medically indicated. Therefore, monitored anesthesia care (MAC) provided during a colonoscopy was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 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 the medication Forteo.The submitted documentation does not support that the requested medication is medically necessary. Authors state that in patients with newly diagnosed osteoporosis, suggested laboratory tests to identify secondary causes include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone. They state that first-line treatment to prevent fractures consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. Raloxifene, teriparatide, and denosumab are alternative effective treatments for certain subsets of patients and for those who are unable to take or whose condition does not respond to bisphosphonates. In this case, while the patient has low bone mass based on Z score and a history of tibial fracture under unknown circumstances, she has not tried and failed first-line therapy for her osteoporosis which includes oral or IV bisphosphonates. In addition, the submitted documentation does not identify any definitive contraindication to oral or IV bisphosphonates. Under these circumstances, the requested medication Forteo is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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.