Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Integrated BRACAnalysis with MyRisk Update Test.  Findings:  Two of the three physician reviewers found there is sufficient support for a portion of the services at issue in this clinical setting. Although this patient was a candidate for BRCA testing, the records indicate that BRCA testing was already performed previously. Thus, repeating this testing was not indicated. Given this patients history, BRACAnalysis Rearrangement testing was medically indicated. However, MyRisk testing was not indicated, since there is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar tests with improved overall survival or quality of life. In sum, BRACAnalysis Rearrangement testing was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of the remaining tests has not been established. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician 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.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement and authorization and coverage for custodial care services at a skilled nursing facility. The submitted documentation does not support that the services at issue and requested services were, or are, medically necessary. The patient is presumed to have sustained some type of spinal cord injury or injuries years ago. More recently, however, the patient had mostly normal strength in all 4 limbs. There were no bowel or bladder issues, and imaging review noted no residual pathology in the spinal cord or other neurological structures. The patient has had problems with his right leg which appear to be primarily orthopedic in nature. Notably, the patient fractured his right leg in the remote past and developed a chronically short right leg. While he has been unable to functionally and safely ambulate, he has been able to use a wheelchair for independent mobility. Based upon the submitted documentation, the patient has had no medical, nursing, or rehabilitation issues that have required care or ongoing care in a skilled nursing facility. The patient has chronic functional impairments without indication of a prospect for functional improvement. He is otherwise independent at a wheelchair level, possibly requiring minimal levels of custodial level assistance as needed for toileting. This level of assistance can be provided by a nonprofessional caregiver, and the patients use of a wheelchair for mobility does not require skilled nursing facility level care. Based on the submitted documentation, the patients care could be safely provided in a lower level of care than at the skilled nursing level. Therefore, reimbursement and authorization and coverage for custodial care services at a skilled nursing facility were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and 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 Omega-3 Acid Ethyl Esters for treatment of his medical condition. Findings: The physician reviewer found that  Omega-3 Acid Ethyl Esters is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Omega-3 fatty acids have been demonstrated in numerous studies to be of potential benefit in IgA nephropathy. In addition, the side effect profile is good and it is considered the standard of care in this clinical setting. In sum, the requested services to be utilized in the management of the patients medical condition are medically necessary given the support in the evidence based literature.  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 physician reviewer is board certified in internal medicine with sub-specialty certification in nephrology 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: The patient has requested reimbursement for monitored anesthesia care (MAC) services. Findings:  The physician reviewer found that current guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) for sedation and anesthesia in gastrointestinal endoscopy noted that, We recommend 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 (Early, et al.). In addition, the ASGE stated that, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III. Wernli and colleagues concluded that the use of anesthesia was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient presented for a routine esophagogastroduodenoscopy and colonoscopy. The patient did not have any documentation of significant heart, lung, kidney, or liver disease. There is no documentation of a history of alcohol or substance abuse, or detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies. The patient was given an ASA classification score of 1 and there is no evidence that she presented with a difficult airway. The ASGE guidelines do not support the use of MAC services in this patient who does not have significant health conditions or airway concerns. Based on these findings, the MAC services were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick 140 mg for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient is a female with known cardiovascular disease, severe hyperlipidemia and documented intolerance to multiple statin medications and Zetia. The intolerance reported is consistent with published criteria that lists severe myalgias as an occasional reported intolerance. Repatha is a PCSK9 inhibitor studied in and approved for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. Repatha has been demonstrated in the peer-reviewed literature to improve patient outcome in this clinical setting. Thus, the use of Repatha Sureclick 140 mg is medically reasonable and appropriate for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility services for treatment of the enrollees medical condition status post multiple trauma injuries.  Findings: The physician reviewer found that the request for skilled nursing facility services have not been established as medically necessary in this clinical setting. The American Academy of Physical Medicine and Rehabilitation states that Medicaredefine[s] skilled services as when the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel. According to the documentation submitted for review, the patient has made excellent progress in self-care and functional mobility with skilled therapies. The patient is at a functional level and she does not require inpatient skilled therapy. She may need outpatient physical therapy and/or occupational therapy, but the records do not demonstrate a need for intensive skilled therapy. With time and healing of injuries she will regain weight-bearing status and mobility will improve further. Accordingly, further skilled nursing facility services are not medically for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10 mg. Findings:  The physician reviewer found that the stepwise World Health Organization ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. The CDC states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. There is a lack of medical evidence based rationale given for the increase in Norco by this patients provider or by the patient. There is a lack of evidence regarding the long term consequences with the continual increase of this medication. The records indicate that tolerance has taken place since the start of the narcotics. There has been no difference in pain scores or objective function despite the increase in the amount of opioid medication he is taking. Moreover, there has been no documented improvement with the current amount of Norco. There are no clear objective goals for the higher dose of opioid. Increases in the past appear to have been done only on the basis of pain levels, which is especially concerning since not all other non-pharmacological ways of taking care of the pain have been done. There is no mention of completion of behavior therapy documented despite much research to support its use. Finally, not all non-opioid medication classes have been optimized or tried. For all these reasons, the requested coverage for Norco 10 mg 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has request for Matched Unrelated Donor Search for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has a very aggressive case of acute myeloid leukemia (AML). AML of this subtype is highly chemotherapy-resistant.  Thus, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is being considered.  This patients age makes the allo-HSCT procedure a very toxic procedure that must be weighed with the potential benefit of long-term remission.  On the other hand, allo-HSCT has the best prognosis and chance for disease-free survival.  Recent data on reduced intensity conditioning shows some favorable outcomes for older patients.  At this point, there is a lack of alternatives in this setting.  The patients functional age should be taken into account when assessing her as a candidate for an allo-HSCT.  Pursuing a suitable match at this point is medically reasonable and necessary.  All told, the requested Matched Unrelated Donor Search is medically indicated for the treatment of this patient.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 internal medicine with sub-specialty certification in medical oncology and hematology 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 38-year-old female enrollee has requested authorization and coverage for a computed tomography (CT) scan and magnetic resonance imaging (MRI) for evaluation of the enrollees paroxysmal positional vertigo.  Findings:  The physician reviewer found that The documentation submitted for review does not support a medical indication for the requested diagnostic procedures. There is a lack of support in the peer-reviewed literature supporting the requested diagnostic procedures in this clinical setting. The medical records submitted for review do not demonstrate evidence of severe headaches, cluster headaches, trauma, seizure, fever, vision changes, and abnormal pressure in the head or an abnormal neurological exam. Thus, the medical necessity of either the CT scan or MRI of the brain is not clinically indicated. As such, the request for CT scan and MRI are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that There is a lack of support in the literature for the use of Xeljanz (tofacitinib) in the treatment of rheumatoid arthritis (RA). The 2015 American College of Rheumatology (ACR) guideline, for the treatment of rheumatoid arthritis recommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  The guidelines noted, there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib.  A second TNFi with or without  MTX of non-TNF biologic with or without  agent is recommended over Xeljanz. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA.  There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi.  Smolen and colleagues noted the following, Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors.  There are currently no studies looking at failure of first TNFi agent and a different biologic agent.  In this case, the patient has failed methotrexate, hydroxychloroquine, sulfasalazine, leflunomide.  However, it is unclear if the patient did not respond to the first TNFi (Humira) as this was stopped due to frequent urinary tract infections and a skin reaction attributed to possible latex allergy while taking Humira. Additionally, the patient has not failed a second TNFi or a non-TNF biologic agent as recommended in the 2015 ACR guidelines. The records fail to demonstrate any contraindications to a trial of a second TNFi.  As such, the request for Xeljanz is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that that 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 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

A sixty-four year-old female with congestive heart failure and chronic obstructive pulmonary disease is requesting authorization of home oxygen therapy.  The patient was admitted to the hospital for chest pain and discharged with orders for home oxygen therapy.Reviewers Findings:The reviewing physician found that standard criteria have been established to determine when home oxygen therapy is clinically appropriate and this patient meets none of those criteria.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old male enrollee has requested spine surgery including CPT codes 63047 (removal of spinal lamina), 22842 (insertion of spinal fixation device) for bilateral lumbar L4-S1 laminectomies, medial laminectomies and right diskectomies as well as L4-5 and possibly L5-S1 fusion with instrumentation for treatment of his L4-5 stenosis with claudication and kyphosis, and right L5-S1 intervertebral disc herniation with polyradiculitis.  Findings:  The physician reviewer found that this patient has back and right lower extremity pain for an unknown period of time. He was seen and had an MRI scan last year. He does not have symptoms of a defined radiculopathy (Tarulli and Raynor). In addition, the records do not provide evidence of severe stenosis, neurogenic claudication, spondylolysis, spondylolisthesis, instability, infection, or significant scoliosis, any of which may be indications for lumbar laminectomy and spinal fusion. The patients sensory loss does not match a radicular/dermatomal distribution. He has no weakness, negative straight leg raise, and reflexes are documented to be within normal limits. There has been no mention of what conservative measures he has undergone and failed, if any. His symptoms do not correlate with the MRI scan. As stated by Bambakidis and colleagues, Lumbar fusion is rarely indicated for routine discectomy. In patients with mechanical back or neck pain, surgery should only be considered after conservative measures have been exhausted and a radiographic abnormality is present at the symptomatic level, perhaps with pain concordant with discographic findings. As such, the proposed surgery is not medically necessary or appropriate for treatment of this patients back and right lower extremity pain and the Health Plans denial was therefore appropriate.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested Lyrica for the treatment of his lower back pain. Findings:  The physician reviewer found that while the FDA approved indications for Lyrica do not include radicular low back pain for patients with post-laminectomy syndrome or lumbar radiculopathy, generally accepted standards of practice do permit medications to be used off-label.  Such off-label medication is particularly useful when alternative medications have caused side effects or when off-label use may help to reduce the need for other medications with significant potential side effects. The use of Lyrica on an off-label basis for radicular pain is being increasingly utilized. In particular, Lyrica is a medically appropriate and reasonable option in this clinical setting in which a patient has had side effects from Neurontin (also an off-label medication for this use) and when the use of Lyrica off-label may help to reduce narcotic medication requirements.