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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a computed tomography (CT) scan of the heart. Based on the records provided for review, the patient presented with increased coronary risk with hyperlipidemia and a family history of heart disease but no known coronary disease. In this circumstance of increase coronary risk, current guidelines endorsed by several national organizations do not recommend the routine use of coronary CT scanning to help guide the use of statin therapy. Specifically there is a lack of evidence that treatment change based on coronary CT scanning results yields an improved cardiovascular outcome incremental to that achievable with treatment guided by standard clinical risk profiling and basic lipid analysis. Based on the patients high LDL level and family history of coronary disease, a statin medication is indicated, regardless of results on coronary CT scanning. Thus, the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the CT scan of the heart performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned

An enrollee has requested authorization and coverage for Stelara syringe 90 mg/mL every four weeks. Current medical literature supports continued dose escalation of Stelara at 90 mg every four weeks in this case. The patient had active disease symptoms on Stelara 90 mg every eight weeks. Researchers reported on a large randomized controlled trial demonstrating the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease resistant to anti-tumor necrosis factor (TNF) therapy. This patient has reportedly failed anti-TNF therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. One study showed Stelara dosing at 90 mg every four weeks is frequently used to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four. In this case, the patient has failed multiple conventional and biologic alternatives, and failed Stelara every eight weeks. He did have a response to Stelara, but routinely loses response at four weeks after injections in the setting of a low Stelara level. A return to dosing every eight weeks or a change to another medication may result in complications. For these reasons, the requested Stelara syringe 90 mg/mL every four weeks 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 medication dosage 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen x 2 (split dose over two days) 50 grams each day and Actemra 680 mg every four weeks. Based on the available documentation, this patient presents with biopsy proven B cell-mediated rejection status post kidney transplant in 2016 due to end-stage renal disease. Treatment has included intravenous immunoglobulin (IVIG), Actemra, tacrolimus, and belatacept. Given the ongoing concern for rejection, her provider has recommended an additional course of IVIG followed by monthly Actemra for six doses. Per Choi and colleagues, significant reducing donor specific antibodies (DSAs) has been demonstrated to improve long-term outcomes in patients with antibody-mediated rejection. The authors noted that the development of DSAs post-transplantation leads to chronic antibody-mediated rejection and transplant glomerulopathy. The authors found that Actemra-treated patients demonstrated graft survival and patient survival rates of 80% and 61% at six years, respectively. Moreover, there is support for use of IVIG in this patients clinical setting. For these reasons, the requested Privigen x 2 (split dose over two days) 50 grams each day and Actemra 680 mg every four weeks are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 subspecialty 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

The parent of an eight-year-old male with diagnoses of Aspergers disorder, anxiety disorder and attention deficit hyperactivity disorder (ADHD) is requesting authorization and coverage for Provigil.Reviewers Findings:  The reviewing physician found that based upon the information provided, there is no medical necessity for authorizing Provigil for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female has requested continued occupational therapy for treatment of her medical condition. Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients, based on the studies that have been performed to date. In practice, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for patients with autism. In support of the need for occupational therapy, studies have shown benefits that prevent deterioration and provide significant improvements in activities of daily living (Case-Smith and Arbesman, and Shoener). Overall, OT addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development. Given this patients continued need for improvement in these areas, the requested OT services should be approved. The patient should be reevaluated at the end of the authorized period in order to assess her need for additional therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Zolgensma. Zolgensma was developed for the treatment of pediatric patients younger than two years of age with SMA and bi-allelic mutations in the SMN1 gene. Zolgensma was designed to deliver a functional copy of the human survival motor neuron (SMN) gene to the motor neuron cells of patients with SMA. The U.S. Food and Drug Administration (FDA) has approved Zolgensma as the first gene therapy used in the treatment of patients with SMA. This patient has SMA type 1 and is under two years of age. Given the support in the medical literature, Zolgensma is medically necessary for treatment of this patient. 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 upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous passive motion (CPM) machine for the treatment of the enrollees status post left knee arthroscopic surgery. Findings:  The physician reviewer found that the effects of continuous passive motion on knee range of motion are too small to justify its use.  Final Result: The reviewer determined that the equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus (HCV). Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400-100 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Electric wheelchair, a new walker or repair of the enrollees current walker, handrails for the enrollees home, and bathtub bars. The records provided for review support that this patients diagnoses include cervicalgia, back pain, and chest pain. The documentation does not reveal that there has been a face-to-face evaluation by a physician or a physical therapist of the patient and home determining that the requested items are appropriate for this patient and her home. The records do not include a thorough mobility evaluation or documentation that the patient is unable to perform usual activities of daily living (ADLs) within the home without a power mobility device. There was no formal gait evaluation revealing that she is unable to ameliorate her mobility deficits with an appropriately fitted walker or cane. There was no documentation of a home assessment to ensure that a power mobility device can fit in the doorways and would be safe to maneuver within the home. Thus, the requested electric wheelchair is not medically necessary. In addition, there is no evidence of an evaluation of the patients current walker. Without a recent evaluation of the patient and her current walker, it remains unknown whether the device can be repaired or should be replaced, or if the current cane is the appropriate assistive device for this patient. Thus, the request to replace or repair the patients current walker is not medically necessary. Moreover, there is no evidence of a physical therapy evaluation of the patient or a home assessment to establish that handrails or bathtub bars are required. All told, the requested electric wheelchair, a new walker or repair of the patients current walker, handrails for the patients home, and bathtub bars, are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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 patient is a 25-year-old female who has requested authorization and coverage for a full body scan. The patient has a history of chronic pelvic pain, dysmenorrhea, and menorrhagia. She has undergone three pelvic sonograms, most recently in 2003, with normal results. In February 2003, the patient underwent a hysteroscopy and D&C with negative results. In 1999, she underwent a laparoscopy, which was also negative. She did have an abnormal pap smear, for which she received treatment. The Health Plan has denied authorization for a full body scan on the basis that it is not medically necessary for evaluation of the patients pelvic pain. The patient wishes to undergo a full body scan to rule out any cancer. This request has no bearing on the pursuit of a diagnosis and treatment of the patients problem. There is no medical indication for a full body scan to rule out gynecological disease. Under certain circumstances, a pelvic MRI or CT scan can be considered if ordered by a physician.A patient in whom abnormal bleeding and pelvic pain persists requires a more thorough workup both for the pain and bleeding. Such a workup would include, but not be limited to, referrals to specialists such as a gastroenterologist to rule out gastrointestinal pathology such as polyps or irritable bowel syndrome; an urologist to rule out interstitial cystitis or a renal problem; a neurologist to rule out a neuromuscular problem with referral pain; and an endocrinologist to rule out thyroid or other endocrine diseases.In addition to the above, consideration can be given to producing amenorrhea with a gonadotrophin releasing hormone agonist to explore the possibility of undiagnosed endometriosis. If the symptoms disappear with this regimen, the treatment can be continued. Also, a repeat laparoscopy can be considered. Referral to a gynecologic oncologist may also be appropriate.In summary, a full body scan is not medically necessary for the diagnosis and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested a chest computed tomography angiography (CTA) for an evaluation of his coronary artery disease (CAD). Findings:  Three physician reviewers found that this patient would be classified as high risk for development of coronary artery disease. Aggressive maximal risk reduction therapy was warranted based on risk factors and history alone. Furthermore, CTA is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset and is not medically acceptable replacement for other conventional screening tests within the standard of care (i.e., treadmill stress testing). CTA is also not a medically acceptable substitute for coronary angiography, as CTA would not be able to accurately confirm or exclude important coronary obstruction. In addition, a negative CTA or stress test would not exclude the possibility of important coronary disease in this high risk patient and coronary angiography without any additional non-invasive testing is also a clinically acceptable strategy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalization for treatment of his medical condition. Findings:  The physician reviewer found that in regards to the treatment of cellulitis, patients with mild cellulitis may be treated with oral antibiotics. It is recommended that patients with signs of systemic toxicity or erythema that has progressed rapidly be treated initially with parenteral antibiotics. Parenteral therapy is also appropriate for patients with persistence or progression of symptoms despite appropriate oral therapy.  In this case the patient is not documented to have an active case of cellulitis or that he has failed outpatient treatment with oral antibiotics. Furthermore for the treatment of chronic venous ulcers, venous ulceration is managed with wound debridement, as needed, barrier creams to protect adjacent skin, and wound dressings tailored to the environment of the wound. In this case the patient has been referred to the appropriate subspecialist. The medical record supports that he has not followed up with either the wound clinic or his primary care physician. There is no documentation to support that he has failed outpatient treatment for either venous stasis ulcers or cellulitis. All told, an inpatient level of care for chronic leg wounds with or without cellulitis is not supported as 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), treatment is recommended for all patients with chronic hepatitis C infection, except those with short life expectancies that cannot be remediated by treating hepatitis C by transplantation, or by other directed therapy. However, in this case the patient presents without fibrosis and has a viral load of less than six million IU/mL. In this clinical setting, given the patients viral load of less than six million IU/mL Harvoni for eight weeks is clinically indicated. As such, Harvoni for 12 weeks 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 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: Medical Necessity
Decision: Overturned

The patient is a 62-year-old female enrollee who has daily headaches which have responded to Myobloc and Botox injections. She has an extended history of migraine with worsening of the headaches after two aneurysm surgeries. The patient has been treated with Topamax, Depakote, Neurontin, Inderal, verapamil, amitriptyline, Indocin, and Stadol. She is currently taking Topamax for treatment of both her seizures and her headaches. The patient began treatment with Myobloc/Botox injections about four years ago and the therapy has consistently reduced the severity of her headaches for three to four months and decreased her headache related disability. The patient has requested reimbursement for Botox injections provided from January 2006 through the present and future authorization and coverage for this therapy.  The Health Plan denied her request citing a lack of medical necessity.The patient has persistent migraine and chronic daily headaches. She has failed to respond to at least five preventative medications, and there are several migraine medications that are contraindicated due to her previous aneurysms and seizure disorder.  Myobloc/Botox injections have been used effectively for over four years and the patients pain level is reduced for several months following treatment. Myobloc/Botox injections are clearly beneficial for this patient and continued treatment is consistent with the standard of care within the neurological community. As such, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.