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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Orencia 125 mg/mL ClickJect autoinjector.American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend that if disease activity remains moderate or high despite diseasemodifying antirheumatic drug (DMARD) monotherapy, patients should use combination traditional DMARDS, or add a tumor necrosis factor inhibitor (TNFi) or a non-TNFi biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone. The ACR guidelines indicate that in moderate to high uncontrolled rheumatoid arthritis, TNFi therapies, such as Humira and Enbrel, are appropriate for use. The guidelines also indicate that non-TNFi biologic therapies, which include Orenica, are also appropriate. The guidelines clearly indicate that TNFi and non-TNFi therapies are both appropriate for these cases of uncontrolled rheumatoid arthritis in no particular order of preference. In this case, the patients rheumatoid arthritis has been uncontrolled despite DMARD therapy including sulfasalazine, methotrexate and hydroxychloroquine. The patient continues to report severe pain and inflammation affecting multiple joints including her hands, wrist and right elbow. This is indicative of moderate to high rheumatoid arthritis disease activity. As noted above, ACR guidelines indicate that non-TNFi biologic therapies such as Orencia are appropriate under these circumstances. Accordingly, the requested medication, Orencia 125 mg/mL ClickJect autoinjector, is medically necessary to treat 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for Boosted Exome Proband Test, Ehlers Danlos syndrome panel testing (15 gene test), and Nutri-Spec testing services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that The requested Boosted Exome Proband Test is not medically necessary for evaluation of this patient. This patient has a number of diagnoses, but none have been associated with specific genetic defects. The patients other diagnoses, including fibromyalgia, SIBO, endometriosis, and IBS, are not known to be caused by single gene defects. Additionally, these are not likely to be due to a single, unifying diagnosis of a Mendelian disorder. Accordingly, the requested Boosted Exome Proband Test is not medically necessary. In addition, testing of genes associated with Ehlers-Danlos syndromes is not medical necessary for this patient and is not necessary to make a diagnosis of hypermobile Ehlers-Danlos syndrome. Hypermobile Ehlers-Danlos syndrome is diagnosed or ruled out clinically. The genes included in Ehlers-Danlos syndromes panel testing are for the other causes of Ehlers-Danlos syndromes, each of which has specific identifiable clinical features, and none of which have been described in this patient. Therefore, any concern for hypermobile Ehlers-Danlos syndrome should be evaluated by the patients provider without need for genetic testing. Thus, the requested Ehlers-Danlos syndromes panel testing (15 gene test), is not supported as medically necessary for evaluation of this patients medical condition. Finally, Nutri-Spec testing is not supported as medically necessary for evaluation of this patients medical condition. The Nutri-Spec testing is not Clinical Laboratory Improvement Amendment (CLIA) certified. Further, the U.S. Food and Drug Administration (FDA) issued a warning about the company marketing this testing in December 2014. Given the lack of support or clinical indication for this testing, the requested Nutri-Spec testing is not medically necessary. All told, the requested Boosted Exome Proband Test, Ehlers-Danlos syndromes panel testing (15 gene test), and Nutri-Spec testing services are not medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 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 Cialis once daily for treatment of his medical condition. .  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a diagnosis of erectile dysfunction.  Per the medical records, he has had prior treatment with Levitra and Viagra.  The patient has requested coverage for Cialis once daily, although the Health Plan limits coverage to six per month.  Cialis once daily is an option for treatment of men with erectile dysfunction.  However, the current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy.  Additionally, the diagnosis of benign prostatic hypertrophy is not documented.  There is no documentation of lower urinary tract symptoms, physical examination and diagnostic studies suggesting benign prostatic hypertrophy.  Studies comparing alpha blockers and daily Cialis used a monotherapy have failed to prove superiority of daily Cialis over alpha blocker therapy.  All told, Cialis daily is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in urology 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 18 hours per week of direct applied behavioral analysis (ABA) therapy, two hours per month of parent training and 21 hours per month of supervision for a total of 77 hours for treatment of the enrollees autism spectrum disorder.Findings: The physician reviewer found that according to the documentation submitted for review, ABA therapy is medically necessary for this patient to address the decline in socialization and decreased interest in food. In addition, the provider reports that the patients level of function is higher when the patient is receiving ABA therapy. However, based on the clinical documentation submitted, the hours requested are excessive in this clinical setting. The documentation submitted for review does not demonstrate the patient has self-injurious behaviors, apart from decreased food intake. Based on the clinical documentation submitted for review, 10 hours per week of direct ABA therapy, two hours per month of parent training and 10 hours per month of supervision is medically necessary and appropriate for treatment of the patients autism spectrum disorder. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested Enbrel for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that this patient has a history of psoriasis that has been unresponsive to topical therapies and ultraviolet B treatment.  He does not have documented psoriatic arthritis. The patient has not been treated with any systemic therapy, including methotrexate or cyclosporine.  There is a long history of treatment of pediatric psoriasis with methotrexate and cyclosporine with long-term safety data, as noted by Silverberg.  While the injectable biologics have shown to improve psoriatic lesions in pediatric patients, long-term safety data are not available.  The patient has not failed therapy with a prior systemic therapy, and treatment with Enbrel should be reserved for those treatment failures.  In this patients case, Enbrel is not medically indicated.
Appeal type: Urgent Care
Decision: Upheld

A 39-year-old male enrollee has requested emergency services for the treatment of his acute pharyngitis and early otitis media on the right side. Findings:  The physician reviewer found that this patients symptoms were not acute in onset.  He did not experience any sudden change in his condition.  He did not require any pain control or medical intervention in the emergency department.  The patients symptoms do not meet the prudent layperson definition for an emergency medical condition. The symptoms were not of acute onset or of sufficient severity such that a prudent layperson would conclude that a lack of immediate medical attention would be likely to result in risk of death or disability.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lower back. Findings:  The physician reviewer found that the American College of Radiology (ACR) guidelines, when at patients lower back pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next examination. Records document that this patient presents with chronic low back pain with associated radiculopathy symptoms and numbness. The provider reported that the patient has failed conservative management in the past including physical therapy and NSAIDs. In this clinical setting, an MRI of the lumbar spine is an appropriate examination and could change the patients management, which may include surgical intervention or interventional pain management. Therefore, the requested MRI of the lower back is medically necessary for this patient. 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 diagnostic radiology 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: Upheld

A 64-year-old female enrollee requested pharmacogenetic testing for medical evaluation of her difficulty sleeping.  Findings:  Three physician reviewers found that there is a lack of exploratory and confirmatory studies demonstrating that pharmacogenetic testing is superior to standard testing in this patients evaluation and treatment.  As presented, the records do not document that the patient had failed contemporary medication or non-pharmacologic interventions for sleep disturbance prior to consideration for pharmacogenetic testing.  For these reasons, the pharmacogenetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140). In the peer-reviewed medical literature, researchers reported that OSA is a common condition, primarily caused by narrowing of the nasal and pharyngeal airway. Treatment with continuous positive airway pressure (CPAP) is considered the first-line of therapy. Bilateral submucous resection (CPT code 30140) is a technique to improve the airway and has been beneficial in patients with severe obstruction noted on physical examination. Poirier and colleagues reported that their study demonstrates improved CPAP compliance rates following septoplasty in OSA patients with nasal obstruction. The authors recommended that correction of nasal obstruction should be offered in nasal CPAP-intolerant individuals to improve CPAP compliance. In this clinical case, the patient has had documented evidence of severe left-sided nasal septal deformity and inferior turbinate hypertrophy causing a great deal of the symptoms of obstruction. This patient has been treated with CPAP but became intolerant to the device. Researchers noted that the effect of nasal surgery on obstructive sleep apnea seemed to be greater when there were indications for combined surgery of the inferior turbinates and the nasal septum, compared to when there were indications for septoplasty alone. Given this support, the requested septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140) are likely to be more beneficial for treatment of the patients medical condition than any available medical condition.One reviewer found that the requested septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140) are not likely to be more beneficial for treatment of the patients medical condition than any available 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 otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with sub-specialty certification in plastic and reconstructive 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 50-year-old female enrollee has requested a panniculectomy for treatment of her excess skin. Findings:  The physician reviewer found that the submitted evidence does not establish that the proposed procedure is reconstructive in nature. While the submitted photographs show some hanging abdominal skin, the amount of excess skin is not so great as to constitute an abnormal structure of the body. The patients condition is normal in that the excess skin is not visibly affected by disease or infection in the photographs provided. With regard to general concepts of medical necessity, panniculectomy after weight loss surgery is medically indicated when the pannus is below the level of the symphysis and interferes with activities of daily living, there are skin problems related to the pannus that are unresponsive to medical therapy (at least two incidences within 12 months while on medical therapy) and the patients weight is stable for at least six months. In this patients case, the medical necessity of the proposed surgery has not been established given the absence of documentation of chronic skin problems refractory to conservative treatment over a period of time or interference with activities of daily living. There is a single office visit note of documenting the existence of a rash, and there is no medical record documentation that the rash failed to respond to conservative treatment.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for cervical spine computed tomography (CT) scan with flexion/extension. The American College of Radiology (ACR) guidelines recommended cervical spine CT scan as the initial imaging for patients with prior cervical spine surgery, and new or increasing non-traumatic cervical or neck pain or radiculopathy. The ACR also noted that CT scan of the cervical spine as initial imaging for patients with cervicogenic headaches and new or increasing non-traumatic cervical or neck pain with no neurologic deficit and as the next imaging study for patients with chronic cervical or neck pain, no neurologic findings, and radiographs showing degenerative changes. This patient presents with complaints of severe right-sided neck pain with painful numbness from the right occipital area down into the right trapezius. She has also described a sensation in the right V3 distribution with the onset of neck pain, and a waxing and waning sensation of dizziness and aural tingling. A nuclear medicine bone scan has suggested some inflammatory uptake of the right occiput to C1 joint. In addition, she has an extensive amount of midline atrophy and scar tissue, which could be contributing to her pain at the craniocervical junction. A recent cervical MRI showed no significant spinal canal or foraminal stenosis, and evidence of a Chiari decompression. Current radiology guidelines support the requested imaging in this setting of prior surgery and increasing non-traumatic pain. Given the patients progressive symptoms, failed conservative treatment and potential for serious spinal instability, a CT scan is medically indicated. Therefore, the requested cervical spine CT scan with flexion/extension is medically necessary for evaluation of the patients medical condition.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 29-year-old male enrollee has requested coverage for past transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient's depression began with symptoms including depressed mood, anhedonia, lethargy, sleep disturbances, decreased self-esteem, social withdrawal, indecisiveness, hopelessness and impaired function. He had experienced a negative response to Zoloft with agitation and increased suicidality to the point where he was unwilling to attempt additional medication trials. The patient was treated with psychotherapy and cognitive therapy for his condition. He was recommended for TMS therapy by his treating psychiatrist and apparently responded extremely well with marked reduction in symptoms and tolerating the treatments without side effects. Transcranial magnetic stimulation has been approved since 2008 by the Food and Drug Administration (FDA) and there are numerous studies showing the benefit of the procedure with minimal if any negative side effects. As this patient has not responded to conventional medications for the treatment of his sustained depression, the trial of TMS was a reasonable clinical alternative as the technique has been shown to improve patients with this disorder.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. This patient has triple negative breast cancer that was advanced in presentation and is now metastatic. The records indicate that she is treatment-naive and can expect a response from chemotherapy. The patient reportedly refused treatment with chemotherapy. Decisions regarding chemotherapy should consider patient preference, goals of treatment, the presence of toxicities from previous therapies, and the availability of alternative treatment options. In order to provide these options to this patient, the provider recommended mutational testing with FoundationOne CDx. One study evaluated 86 patients and found that the progression-free survival (PFS) on regimens selected by molecular profiling yielded a 27% survival advantage when compared to PFS on the most recent chemotherapy regimen. Additional data on breast cancer also supports the utility of FoundationOne testing in this patients clinical setting. All told, the FoundationOne CDx comprehensive genomic profiling test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the FoundationOne CDx comprehensive genomic profiling test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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.