Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone injections. The submitted documentation supports the medical necessity of the requested medication. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment, in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. The patient has failed therapy with transdermal testosterone. The patient will benefit from intramuscular testosterone therapy. Therefore, the requested testosterone injections are medically necessary for 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks.Findings: 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), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing in genotype 1a patients should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg tablets daily for 12 weeks is medically necessary for this patient.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found there is sufficient support for a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that providers offer screening for spinal muscular atrophy to all patients who are considering pregnancy or who are currently pregnant. The records document that this patient underwent screening for spinal muscular atrophy. Thus, the medical evidence supports this testing in this clinical setting. However, the submitted documentation indicates that CPT code 81401 is in dispute. This code represents a complete gene panel. The records did not provide further support for the remaining of the tests which were included in the gene panel testing. In sum, screening for spinal muscular atrophy was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remaining tests of the gene panel testing 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 obstetrics and gynecology 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Latuda prescription for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia. In mid-2013, lurasidone gained two additional indications, both for the treatment of bipolar illness, and is one of only three U.S. Food and Drug Administration (FDA) approved medications for bipolar depression.  The other two, quetiapine and olanzapine-fluoxetine combinations, are frequently associated with weight gain, glucose intolerance and dyslipidemia.  The medical evidence appears to indicate that lurasidone is associated with fewer metabolic side effects and less weight gain. The Health Plan suggested aripiprazole as an alternative.  However, the data supporting aripiprazole as a monotherapy or in conjunction with lamotrigine in the treatment of bipolar depression are weak when compared to lurasidone. Lurasidone is approved by FDA for this patients condition and is reasonably expected to improve the patients condition and to prevent a more serious episode of illness.  Therefore, Latuda is medically necessary for the 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for evaluation of the enrollees abdominal pain. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had symptoms and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and has been demonstrated to be superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Per the study by colleagues, the frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography enteroclysis, leading to change in management in a significant number of patients. In this patients case, wireless capsule endoscopy was likely to have been more effective than other available modalities for evaluating this patient.  Final Result: 2/3 of the reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA diagnostic testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, the superior effectiveness of Prometheus Anser ADA diagnostic testing performed has not been established. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that there is currently considerable debate about how best to screen for prostate cancer.  The fact that this patients PSA level is stable does not rule out prostate cancer. Prostate cancer is notoriously slow growing, and the lack of progressive elevation does not exclude a malignancy. In general, PSA levels under 4 are not considered abnormal, whereas levels over 4 are regarded as suspicious.  This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated. There are many options for therapy (radical prostatectomy, observation and monitoring, brachytherapy, external bean radiation), with no single therapy clearly advantageous, and all therapies having significant risks of complication. Accordingly, MRI has become a common imaging procedure to better evaluate the prostate. The American College of Radiology (ACR) provides recommendations to help guide clinicians as to the most efficient and efficacious means to evaluate various clinical entities. In their publication concerning patients who are clinically suspected with prostate cancer and who has had a prior negative transrectal ultrasonography-guided biopsy, MRI is felt to be the most appropriate study to perform. They found that MRI is a useful adjunct for tumor localization in biopsy negative patients, as in this patients case. A study concurs with the ACR assessment, MRUS fusion biopsy provides improved detection of PCa in men with prior negative biopsies and elevated PSA values. Most cancers found were clinically significant.  This patient fits the ACR criteria and the medical literature. All told, MRI is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection to the right knee for treatment of the enrollees knee pain. Findings: The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated stiffness, swelling and weakness. Functional limitations were documented with stairs and prolonged sitting. Clinical examination findings were consistent with the diagnosis of medial compartment osteoarthritis. He has not obtained significant symptom relief with prior conservative treatment, including medications, activity modification, and physical therapy. The records noted that prior viscosupplementation injections had provided significant sustained relief. It was also noted that he was attempting to delay knee replacement surgery given his young age. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Monovisc injection to the right knee 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Danmar soft shell helmet for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that the submitted documentation as well as the medical literature provide support for the requested equipment in this patients case. There is medical literature that documents the association between seizures and head injuries. Head trauma is a common occurrence in patients with intractable epilepsy.  The ramifications of this event can be reduced through the use of a helmet.  In this case, compliance and use of a standard bike helmet would be limited given the patients baseline strength. In the past, the patient has tolerated a Danmar helmet well with reported reduction of head traumas during seizures. To this end, it is reasonable for this patient to continue to use this type of helmet. The patient requires protection from potential risk of head trauma when her seizures occur. For these reasons, Danmar soft shell helmet is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees knee pain. Findings: The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, it is documented the patient has been treated with physical therapy, braces, Norco, and underwent corticosteroid injections. Moreover, the patient is not a reasonable candidate for repeat corticosteroid injections so close to the time of planned revision right knee arthroplasty which might increase risk of periprosthetic joint infection. Previously, the patient has experienced success with viscosupplementation. For these reasons, the requested hyaluronan (Orthovisc) injections in the left knee is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg tablets. Findings:  The physician reviewer found that : Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared to the alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including decreased risk of osteopenia and renal disease. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B.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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compound medication (progesterone micronized 100% powder) provided Findings:  The physician reviewer found that the physician reviewer found that progesterone supplementation is routinely used in assisted reproduction to increase pregnancy success rates.  In this case, the patient was of an advanced maternal age and attempted pregnancy via embryo transfer. As noted by a study, there is little doubt that endometrial receptivity plays a major role in the success or failure of embryo implantation after in vitro fertilization (IVF). To optimize endometrial receptivity, it is common practice to administer a progesterone supplement during the luteal phase. Thus, treating this patient with micronized progesterone was medically appropriate. In this patients case, the provider recommended micronized progesterone suppositories, and there are no prescription suppositories currently manufactured by a pharmaceutical company.  The medical evidence supports the medication at issue in this clinical setting. All told, compound medication (progesterone micronized 100% powder) provided during the dates of dispute was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The documentation submitted for review does not demonstrate evidence of an emergency medical condition. The medical records provided for review, fail to show past medical history addressing a mechanism of injury leading to the reported acute presentation or evidence of chronicity. In addition, there is no documentation of imaging to rule out underlying injury/pathology that would lead to the reported emergency presentation. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oriental medicine and chiropractic 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.