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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade 600 mg every four weeks. The submitted documentation supports the medical necessity of the requested medication regimen. The U.S. Food and Drug Administration (FDA) approves the use of Remicade for the treatment of ulcerative colitis. Gibson and colleagues note that an intensified infliximab dosing strategy in response to clinical or laboratory signs of breakthrough inflammation may be required to produce a more therapeutic effect. Dumitrescu and colleagues note that infliximab dose doubling to 10 mg/kg led to short-term and long-term event-free survival in patients with ulcerative colitis, who had a loss of response to infliximab, in greater than 50% of the cases. Reinisch and colleagues report in a study of adults with moderate-to-severely active ulcerative colitis that long-term treatment with infliximab for up to three additional years was effective and well tolerated. The American College of Gastroenterology (ACG) guidelines on the treatment of ulcerative colitis support increasing the infliximab dosage in patients with uncontrolled disease. The American Gastroenterological Association (AGA) guidelines for management of ulcerative colitis support increasing the infliximab dosage in patients with a low infliximab level, as in this case. AGA guidelines on therapeutic drug monitoring in inflammatory bowel disease note that an infliximab dose increase is needed when there is a low drug level. In this case, the patient has uncontrolled clinical disease, and a history of inflammation on colonoscopy with the current dosage, placing the patient at risk for colorectal cancer and severe disease flare. Continuing with the current dosage may lead to risk for a disease flare requiring hospitalization or surgery, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. In this clinical setting, the requested medication regimen is medically indicated. Remicade 600 mg every four weeks is medically necessary to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; and to correct or ameliorate any physical or behavioral conditions. Therefore, Remicade 600 mg every four weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Overturned

The parent of a 1-year, 11-month-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CPT code 78815 - positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh for evaluation of her breast cancer. Findings:  The physician reviewer found that this patient has had routine post treatment mammography and the most recent demonstrated no evidence of recurrence. The patients most recent PET/CT showed no sign of malignancy. There are no clinical findings to suggest tumor recurrence per the submitted records and no imaging studies suggestive of same to warrant follow-up. The National Comprehensive Cancer Network (NCCN) guidelines are specific in that there is no recommendation for surveillance imaging or lab tests absent a clinical finding to suggest tumor recurrence or metastatic disease. Final Result: The reviewer determined that the requested diagnostic procedure is 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 Vicodin (hydrocodone 5 mg and acetaminophen 325 mg) for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. In this patients case, all non-opioid treatment options have not been utilized. The records do not document the completion of behavior therapy despite much research to support its use. It is reasonable to consider alternatives to opioids and to wean the patient off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. Epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. Multiple minimal requirements for opioid prescribing have not been done, and the need to use them as the primary medication treatment strategy for pain has not been established. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested speech therapy for treatment of her medical condition.  Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The services at issue are supported by the medical literature in this clinical setting. Researchers assessed the effectiveness of speech and language therapy (SLT) for aphasia following stroke. They concluded Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. Based on this review SLT appears to have efficacy in the treatment of aphasia secondary to stroke. In this case, the patient has shown improvement with speech and language therapy. As such, speech therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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:   All three reviewers are board certified in physical medicine and rehabilitation and are 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 54-year-old male enrollee has requested a consultation to evaluate his sinus status and needs, including surgery for turbine implants for treatment of his medical condition. Findings:  The physician reviewer found that this patient has had multiple consultations regarding the status of his nasal symptoms.  Many of these symptoms were present prior to his third surgery, and so they cannot be attributed to reduction in size of the inferior turbinate. In addition, other than a single subjective assessment of his turbinate size, there are no other such subjective or objective assessments that this patients left inferior turbinate is hypoplastic. Furthermore, there is also no recommendation by any physician in the submitted records for inferior turbinate augmentation, other than possible in-fracture of these structures. Finally, the scientific medical literature is sparse regarding the overall efficacy of these procedures. In summary, another consultation is not medically necessary for the treatment of this patients chronic sinus disease. His symptoms are chronic and no evidence has been presented that further surgical intervention will be curative. There is no support in the descriptions given in the medical records that inferior turbinate implants would resolve this patients symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested positron emission tomography (PET) for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the use of PET scans is becoming a standard of care in the behavioral neurology specialty. PET scans have been studied in the diagnosis of dementia for over 15 years. In a 2007 article, by Weaver and colleagues, they concluded that this technology has enough evidence to recommend it as an aid in the diagnosis of dementia. The most recent Cochrane meta-analysis of this subject suggests that this technology should not be routine, but that it has a role in cases without a clear diagnosis. In this case, the patient is observed to have a clinically significant cognitive disorder without a diagnosis. His findings could be related to severe depression mixed with attention deficit hyperactivity disorder, frontotemporal dementia, or atypical Alzheimers disease. Making an accurate diagnosis will allow the patient to plan his future, and assist his providers to develop a treatment plan. He underwent standard evaluation including EEG, MRI, and neuropsychological testing; but, no clear diagnosis is forthcoming.  In sum, the requested PET scan is likely to be superior over other alternatives for evaluating this patient.Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in neurology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment, substance use disorder, detoxification services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that upon review of the submitted documentation, the medical necessity of substance abuse residential treatment for detoxification has not been established.  The submitted records do not document he had prior treatment at lower levels of care. Nor is there evidence the patient had attempted to withdraw unsuccessfully on his own. The patient was medically and psychiatrically stable during the admission. The staff reported that he was motivated and engaged in treatment. As such, the patient could have been safely and effectively treated on an outpatient basis, which is common practice in the community in patients with mild to moderate withdrawals. All told, the patient did not require 24-hour supervision at a residential level of care during the period at issue. Thus, the residential treatment, substance use disorder, detoxification services were not medically necessary. Final Result: The reviewer determined that 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 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 has been diagnosed with psoriasis vulgaris. In the Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted clobetasol, lidex foam, and betamethasone had provided mild control of the patients psoriasis. The provider noted that the patient had a history of skin cancer and breast cancer. The provider noted biologic injectables would compromise the patients immune system. Per the records, the patient has been taking Otezla, with decreased flares. the records indicated that the patient had been treated with photodynamic therapy for her face. The patient has requested authorization and coverage for Otezla tablets. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla tablets are medically necessary for the treatment of the patients medical condition. Studies  reported, As elevated levels of tumor necrosis factor-alpha (TNF-) are associated with disease severity in psoriasis and psoriatic arthritis, TNF- antagonists are being used to treat moderate to severe disease in patients who have contraindications, fail to respond or develop side effects to conventional systemic therapies. Per the authors, Some of the common side effects include infusion and injection site reactions, infections  particularly reactivation of tuberculosis, autoantibody formation and drug induced lupus erythematosus, liver function abnormalities, hematological, and solid organ malignancies. A study revealed, Apremilast demonstrated significant improvements in mean percentage change in the Psoriasis Area and Severity Index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. Researchers reported, Apremilast was effective in the treatment of psoriatic arthritis, improving signs and symptoms and physical function. Apremilast demonstrated an acceptable safety profile and was generally well tolerated. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. She has a history of skin and breast cancer. Immunosuppressive medication can increase the risk for infection and malignancy. The medical evidence supports the requested medication in this clinical setting. Therefore, Otezla tablets are medically necessary for the 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 overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS).Findings:  The physician reviewer found that this patient has a long documented history of treatment-resistant depression. Despite adequate trials of multiple medications as well as ongoing evidence-based psychotherapy, the patient continues to experience refractory depression, which has significantly interfered with her ability to function. The patient previously noted substantial symptomatic improvement with a past course of TMS. Given the treatment refractory nature of this patients major depressive disorder, numerous trials of alternative treatments for her condition, and only positive response to a course of TMS, the medical literature supports a repeated course of TMS (McClintock, et al.). Moreover, the requested TMS is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested TMS is medically necessary 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 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: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for SPRINT peripheral nerve stimulator. Helm and colleagues assessed nine studies evaluating the effectiveness of peripheral nerve stimulation (PNS) for the treatment of patients with chronic pain conditions. The authors found that PNS requires further documentation of its effectiveness and expansion of its indications in order to become more widely accepted. Another review by Kaye and colleagues reported that, Further studies are needed as the long-term risks and benefits of peripheral nerve stimulation have not been well studied as most information available on the effectiveness of peripheral nerve stimulation is based on shorter-term improvements in chronic pain. In this case, the patient has chronic chest wall pain due to a variety of factors including thoracic outlet syndrome, thoracic neuroforaminal  narrowing with radicular pain, and pectus excavatum status post video assisted thoracoscopic surgery (VATS) procedure. The patient has tried and failed several treatment modalities including pulsed radiofrequency neuromodulation, physical therapy, nerve blocks, acupuncture, steroid injections, and a spinal cord stimulator. The provider has recommended a single stage 60 day peripheral nerve stimulator treatment. However, there is a lack of clinical studies demonstrating that peripheral nerve stimulator use is safe and effective for patients with intercostal neuralgia. In addition, there is a lack of data showing that peripheral nerve stimulator use is superior to standard available therapies. Based on these findings, the requested SPRINT peripheral nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested services are not 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 services are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested a home birth with a certified professional midwife for medical treatment of her pregnancy.  Findings:  The physician reviewer found that the medical literature noted concern regarding the increased risk of neonatal death with home birth.  Per the current medical evidence, planned home birth is associated with a twofold to threefold increased risk of neonatal death as compared to planned hospital birth.  As noted by the medical literature, hospitals and birthing centers are the safest setting for births in the United States.  All told, the requested home birth with a certified professional midwife is not medically indicated for the treatment of this patient.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 obstetrics and gynecology 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 parent of a 17-year-old male enrollee has requested for growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that although there are no significant studies showing that GH therapy can be used to induce increased growth in cystic fibrosis or to counter growth retardation from therapeutic steroids, it appears to have yielded positive results in this instance. Given the severity of the patients growth failure, I believe a six-month trial of GH therapy is clinically indicated to see if additional growth can be induced.