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

The patient is a 32-year-old male with apparently well-documented cutaneous psoriasis, with extensive involvement of trunk and all four limbs. Records from his dermatologist and his primary physician make only one mention that the arthritis still affects the knees and the ankle joints, and this is not described elsewhere in the record. The dermatologist states that the patient has failed trials of Soriatane, oral prednisone, and topical triamcinolone, and further notes that methotrexate is contraindicated because the patient drinks alcohol. Nonetheless, the dermatologists last note of 1/30/04 states the patient has been started on methotrexate 7.5mg per week.The diagnosis of psoriatic arthritis is not established by the medical records. Cutaneous psoriasis itself is obviously very common, and is appropriately managed by dermatologists. In the management of patients with psoriatic arthritis, among whom a wide spectrum of cutaneous psoriasis is seen, it is quite obvious to all involved that tnf inhibitors produce major and sometimes dramatic improvement in skin manifestations, along with the joint benefits. Most providers using these drugs fully expect that drugs such as Enbrel will become accepted, standard therapy for cutaneous psoriasis itself in the near future. Tnf inhibitors combined with Enbrel or related drugs is not yet standard therapy for psoriasis in the absence of psoriatic arthritis.This patient needs evaluation by a rheumatologist to determine if he indeed has psoriatic arthritis, and, if so, to then consider therapeutic options. The use of methotrexate for psoriatic arthritis remains standard and often very effective treatment, for which the short-term toxicities and long-term risks are well understood and quite acceptable. The contraindications to methotrexate use primarily relate to pre-existing or active liver disease of certain types, and to uncontrolled alcohol abuse. The dermatologists statement that methotrexate would be contraindicated in this patient because the patient drinks alcohol would only be correct if the patient had a disorder of alcohol abuse; occasional alcohol use in moderation is acceptable behavior in the rheumatologic community, as the actual liver toxicity of methotrexate at anti-inflammatory dose levels has proven to be minimal. If this patient were shown to actually have psoriatic arthritis, then a trial of methotrexate by a rheumatologist would be accepted and standard therapy. In the event methotrexate fails due to lack of benefit or due to intolerable side effects, then the use of tnf inhibitors such as Enbrel would be appropriate and standard treatment. However, without a diagnosis of psoriatic arthritis and unless the patient fails an appropriate trial of treatment with methotrexate, Enbrel is not indicated. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 25-year-old female enrollee requested authorization and coverage of intravenous Remicade therapy. The Health Plan  denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees positive HLA-B27 spondyloarthropathy with ankylosing spondylitis.  Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his  autism.  Findings:  The physician reviewer found that the standard of care guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 also advocates in favor of a comprehensive multidisciplinary approach utilizing providers with various specialties. This patients provider has clearly outlined a treatment plan with specific goals and approaches for attaining those goals. The records also reveal that the patient has already made moderate gains in some area, but continues to require intervention.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested SymlinPen for treatment of her diabetes mellitus. Findings:  The physician reviewer found that in this patients case, the submitted documentation fails to establish the medical necessity of the requested SymlinPen.  Symlin is indicated when hemoglobin A1C is less than or equal to 9 to help optimize blood glucose control.  This patients hemoglobin A1C was higher on two occasions.  Symlin is used to supplement mealtime insulin, and not take its place. In this clinical situation, considering the patients hemoglobin A1C levels, there may be an issue regarding the insulin dosage.  The current medical evidence does not support the requested medication in this patients case.  All told, the requested SymlinPen is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the diagnostic procedure at issue in this clinical setting. In this case, the patient has a family history of breast cancer in her mother. In this particular case, the patient does not meet criteria for breast magnetic resonance imaging (MRI) screening, however given the patients high risk of developing cancer, breast tomosynthesis was clinically indicated and was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Ensure nutrition supplement shake.According to medical literature, lower protein intake was associated with increased risk of mobility limitation in community-dwelling, initially well-functioning older adults. Additionally, the study by researchers found that protein intakes of greater or equal to one gram per kilogram body weight per day may be optimal for maintaining physical function in older adults. Weight loss in older adults is multifactorial. The approach to undesirable weight loss includes lifting dietary restrictions, supplementing diets with nutrient dense food or adding milk powder/whey protein/egg whites or tofu to the food. Taking a daily multivitamin is also important. If these interventions are ineffective, a nutritional supplement can be considered. Nutritional supplementation can result in modest improvement in percentage weight gain. Additional treatment can be in the form of appetite stimulant medications. In this case, the documentation does not support that the patient has had significant weight loss or could not be treated with a soft or blended diet/supplement. There is no documentation to support that she is underweight or has any disorders that prevent her from chewing her food or swallowing solid foods. Additionally, there is no indication that she has met with a nutritionist or has been supplementing her own diet with high protein supplements or fats. Therefore, Ensure nutritional supplement shake is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested supplement 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 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

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for wound product (stem cell injections). The submitted documentation fails to demonstrate the superior efficacy of the services at issue. Stem cell implantation has been utilized successfully for the treatment of diabetic wounds and burns. There is research demonstrating some efficacy of stem cells in the treatment of osteoarthritis and regeneration of cartilage. However, the research is relatively new, and small studies have demonstrated minor effectiveness. Cheilectomies have been performed for many years to the first metatarsophalangeal for the successful treatment of hallux limitus/rigidness. In this particular case, the records do not demonstrate that the addition of the stem cells would be more beneficial than the standard surgical treatment alone. Therefore, wound product (stem cell injections) was not likely to have been of greater benefit than other treatment options. Findings:  Three medical professional reviewers found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in podiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches. Findings:  Two physician reviewers found that the medical records suggest a transformation from episodic migraine to chronic daily headaches. Historically, frequent use of non-steroidal anti-inflammatory drugs (NSAIDs) and pain medication is noted. It is likely this patient has transformed migraine (i.e., chronic daily headache). Current evidence-based opinion is that Botox is most likely ineffective for patients with chronic daily headache. Based on four Class II studies, there is insufficient evidence to support a benefit of Botox for treatment of chronic daily headache.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Acthar Gel injections for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that initially, Acthar Gel was indicated for treatment of this patients significant multiple sclerosis exacerbation. However, as significant time has elapsed since the exacerbation, the treatment is no longer indicated. Acthar Gel is marketed as treatment for multiple sclerosis exacerbations in patients who either did not respond, or have side effects to standard treatment with high dose IV Solu-Medrol. Several studies have shown non-inferiority of Acthar Gel as compared with IV Solu-Medrol. However, there are some patients who benefit from Acthar Gel with fewer side effects than high dose oral prednisone or high dose IV Solu-Medrol. At this time, this patient is no longer experiencing an acute relapse, and therefore the requested Acthar Gel injections are not medically necessary. 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 and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lyrica for treatment of the enrollees polyneuropathy due to acquired immunodeficiency syndrome (AIDS).   Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of peer-reviewed literature supporting Lyrica in this clinical setting. Simpson and colleagues performed a randomized, double-blind, placebo controlled trial to evaluating Lyrcas efficacy, safety, and tolerability for treatment of painful human immunodeficiency virus (HIV)-associated neuropathy. The authors concluded that Lyrica was well-tolerated, but not superior to placebo in the treatment of painful HIV neuropathy. Factors predicting analgesic response in HIV neuropathy warrant additional research. There is a lack of medical literature showing that Lyrica is more effective than placebo for the treatment of HIV neuropathy. As such, Lyrica is not clinically indicated in this clinical setting. Based on the lack of support in the peer-reviewed literature, Lyrica 50 mg two times daily is not 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 infectious 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 SLSA functional electrical stimulator (FES). In this case, the patient has a diagnosis of locked-in state. Emphasizing the need for significant multidisciplinary rehabilitation, Researchers report that multimodal treatments that are frequent and sensory can provide significant improvement for patients with locked-in syndrome. The authors further note that FES has been found to be particularly beneficial. Researchers explain that locked-in syndrome is a rare condition that results in tetraplegia and that although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described.  Because locked-in syndrome is so rare, there is a lack of high quality studies that examine the efficacy of various treatments. In this case, the provider reported that the patient had some motor function and was improving functionally with the upper and lower extremities with use of the RT300 FES. As FES has been demonstrated to increase muscle mass in patients with spinal cord injured patients, it is reasonable that FES would increase the muscle mass in patients with tetraplegia from other etiologies, like locked-in syndrome. Without treatment, the patient will continue to lose muscle mass and function, and there are no obvious viable treatments other than FES that can maintain, or increase, muscle mass for a patient with locked-in syndrome. Therefore, the RT300 SLSA FES is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested RT300 SLSA FES is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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: Physician reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone for treatment of the enrollees pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested medication quantity. Per the records, the patient was stable on 120 mg per day of methadone. She was able to perform her activities of daily living, and this dosage of methadone controlled her pain to a significant degree. Dowell and colleagues noted established patients already prescribed high dosages of opioids (greater than or equal to 90 MME per day), including patients transferring from other clinicians, should be offered the opportunity to reevaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan. This statement does not mandate immediate reduction in dosage. Nuckols and colleagues found that while high dose methadone has higher risks, following guidelines can mitigate that risk.  The authors noted guidelines also agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations are supported by observational data or expert consensus.  A maintenance agreement and urine toxicology were obtained in this patient, and she was compliant.  There is no indication of diversion or of not following directions. The patient should be maintained on methadone 120 mg per day and given the opportunity to begin a gradual taper.  The dosage of methadone 120 mg per day is medically necessary. All told, a portion of the requested medication quantity is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication quantity 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 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

The parent of an enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The documentation provided does not support the medical necessity for the services at issue in this clinical setting. The records do not indicate that this patient had any episodes of self harm. She did not have any suicidal thoughts or thoughts of self harm. The patient was described as sleeping well and had good energy. She had a good appetite and good focus. The provider reported that the patient had no side effects from the medication. The provider did not make any medication changes at the time. A record noted the patient was given a pass to leave the residential treatment facility to visit home. Other notes corroborate the patient did not have self harming behaviors and had an improved mood.  While the patient continued to need treatment for her behavioral health condition, her treatment could have been provided in a less restrictive environment. Therefore, residential treatment center services were not supported as medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined the services at issue were 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 psychiatry with expertise 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

A 50-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her diabetes mellitus, hypertension, and sleep apnea.  Findings:  The physician reviewer found that based on review of the available records, although this patient is morbidly obese and may benefit from a bariatric procedure, she does not meet all standard primary criteria for bariatric surgery at this time including the National Institutes of Health (NIH) consensus guidelines. The records do not include documentation of a dietary evaluation, behavioral evaluation, or medical clearance for bariatric surgery. In addition, the patient indicates that she has failed dietary efforts in the past but there is a lack of evidence of supervised dietary efforts at weight loss. All told, the requested bariatric surgery is not supported as medically necessary for treatment of this patients medical condition.