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

A 48-year-old male enrollee has requested Serostim for treatment of his HIV-associated wasting syndrome.   Findings:  The physician reviewer found that The study cited by Moyle and others demonstrated that Serostim improved lean body mass, physical performance and quality of life in HIV-infected infected patients receiving highly-active antiviral therapy. This placebo-controlled trial delivered the drug for a period of 12 weeks. While the manufacturers prescribing information does not define an optimal duration of treatment, the research that documented the efficacy of the treatment was a 12-week study. Variable, longer-term regimens of this drug therapy have been suggested, but there are no published, controlled trials demonstrating a benefit with extended use Serostim. There is no evidence that extending this patients treatment with Serostim would be of benefit.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested a referral to a gastroenterologist for treatment of his ulcerative colitis. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient has a long-standing history of ulcerative colitis. Generally, primary care physicians do not have the training, experience, and expertise necessary to provide long-term care for patients with ulcerative colitis. Even though his colitis is in remission, the patient should be under the care of a gastroenterologist who has expertise and experience in providing ongoing management of such patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia ClickJect 125 mg subcutaneous weekly. The records provided for review document that this patient has a history of rheumatoid arthritis and protein S deficiency. The provider charted that prior treatment with Enbrel was ineffective and not well tolerated. The provider noted that additional anti-TNF agents are not recommended in this clinical setting. The provider has recommended treatment with Orencia. According to the American College of Rheumatology guidelines, it is recommended for patients to switch drug classes rather than use another form of anti-TNF therapy. The patients protein S deficiency increases her risk for thrombosis, and she is on chronic anticoagulation therapy. Rinvoq and Xeljanz are contraindicated for this patient since these agents have been associated with an increased risk of thrombosis development. Given these findings, the requested Orencia ClickJect 125 mg subcutaneous weekly 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 overturned. Credentials/Qualifications: The reviewer is board certified 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic test (Afirma Gene Expression Classifier) for evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewer found that While a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, Afirma Gene Expression Classifier was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: Two of three 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 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni one tablet daily for a duration of 12 weeks for treatment of her hepatitis C. 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  All told, Harvoni one tablet daily for a duration of 12 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that found the submitted documentation supports the medical necessity of the services at issue. This patient reported an early age of first use of alcohol. She self-medicated with alcohol, and her alcohol use was complicated by co-occurring depression and anxiety. The patients alcohol use and psychiatric symptoms were impairing her daily routine and contributing to significant impairment across multiple domains of functionality. She was drinking daily to the point of blackout. Finally, the patient had been treated at various levels of care over the years, but had been unable to maintain sobriety or harmonious euthymia in the outpatient setting. The treatment provided during the dates of service in dispute focused on aftercare planning and treatment consolidation with the application of complex pharmacotherapy and core elements of both cognitive and dialectical behavior therapies. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services at issue were reasonably expected to improve her condition and prevent a more serious episode of illness.  Therefore, partial hospitalization program services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Overturned

The patient is a six-year-old male diagnosed with autism spectrum disorder, including significant speech and language delay. He has been in individual speech and language therapy since April 2001. A report from the patients speech therapist in November 2003 indicated the patient experienced significant improvement in all areas. The Health Plan indicates that continued individual speech therapy is not medically necessary due to a lack of documented functional progression over the past three to six months.Intense speech and language therapy is often helpful in the treatment of autism spectrum disorder. The patient has been in individual speech and language therapy since April 2001. The detailed and thorough speech and language therapy progress reports document significant functional progress, specifically in the areas of gestures, play, and language comprehension and language expression. The submitted existing evidence suggests that the patient is making progress and that continued individual speech therapy is medically indicated. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The patient should receive three-60 minute sessions of speech therapy per week. The patients progress should be reevaluated at least quarterly and should be continued as long as significant functional progress is demonstrated. As such, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested a right breast magnetic resonance imaging (MRI) for evaluation of her 2cm density in the right breast. Findings:  Three physician reviewers found that the demonstration of a measurable 9 mm hypoechoic focus with internal vascularity is an indication for ultrasound guided core biopsy. Further, MRI is not a substitution for tissue sampling of a suspicious ultrasound finding. The radiologists report states the area seen on ultrasound may correlate to the mammographic finding. However, this statement does not provide enough equivocation to indicate further imaging such as MRI. Consistent with this patients medical condition and the available peer-reviewed medical literature, the requested right breast MRI is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for oxycodone/acetaminophen 10/325mg, every four hours. The submitted documentation does not support that the requested medication regimen is medically necessary. The Centers for Disease Control (CDC) clinical practice guidelines clearly delineate that opiates at a high dose are not appropriate for chronic non-malignant pain. Researchers indicate that the risk of overdose dramatically increases when greater than 50mg of morphine equivalent per daily dosage (MED) is prescribed, which would be the requested MED dosage by the patient. In this case, the patient seeks more frequent opiate dosing to treat chronic non-malignant pain. The requested dosing would amount to a MED dosage that statistically carries a greater risk of overdose. The submitted records reflect that the patient has made this request while numerous other medications and other therapeutic options have been declined but remain available. Under these circumstances, the requested medication regimen of oxycodone-acetaminophen 10/325mg, one tablet every four hours, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication regimen 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 subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fetal chromosomal microdeletions provided. There is a lack of evidence in peer-reviewed literature from large, randomized trials or high-quality prospective observational trials supporting the clinical utility and impact on patient management of nucleic acid sequencing-based testing of maternal plasma for microdeletions. Researchers note that cell-free fetal DNA non-invasive prenatal testing (NIPT) performance is affected by the condition under investigation. The sensitivity and specificity of screening tests for microdeletion syndromes, which may occur sporadically or due to other genetic mechanisms, has not been validated in clinical studies. Therefore, the provided maternal blood testing for fetal chromosomal microdeletions was not likely to have been more beneficial for the evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the maternal blood testing for fetal chromosomal microdeletions at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility and is actively practicing, Physician reviewers 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested reimbursement for mental health inpatient stay of four days.  Findings:  The physician reviewer found that the hospital progress notes and discharge summary indicate that the patient was no longer in any danger of harming herself and was stable enough for discharge by the third day. The letter from the provider reports that the patient was kept in the hospital on the third day so that a family session with her mother could be held on the fourth day. The mother was out of town until the evening of the third day and was not available for the session that day. However, the definition of medical necessity includes a statement that the care being provided is not solely for the convenience of the facility or the patient. In this case, the extra day of hospitalization was for the benefit of the family. Had the patients mother been available for the family session one day earlier the patient could have been safely discharged that day. Thus, medical necessity criteria are not met for the inpatient mental health services provided on the third and fourth days. All told, the services provided to this patient the first two days were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old woman with bilateral knee pain due to osteoarthritis. She was given Synvisc injections in April 2005 and again in December 2005. She underwent injections in each knee and good results were indicated by her orthopedist.  The patient has requested reimbursement for the cost of the therapy.  The Health Plan denied the request based on a determination that the therapy was not medically necessary for treatment of the enrollees knee pain.The patient had her first series of Synvisc injections in April and had good relief for over six months.  In light of her previous response to the therapy, a second series was medically appropriate.  The second series was again successful, and her orthopedist reported that the patient was able to decrease her pain medications by 50%. Therefore, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested orally administered Lamisil 250mg for treatment of his onychomycosis. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the patient has any documented immune impairment. Additionally, there is no documentation by the physician indicating functional impairment due to onychomycosis, including loss of toenails or swelling. Based on the information provided, it does not appear that a fungal culture has been obtained. Furthermore, there is no documentation that the patient has comorbidities that would require treatment with Lamisil. In this patients case, orally administered Lamisil 250mg is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Inspire device (hypoglossal nerve stimulator). Findings:  The physician reviewer found that As noted in the medical literature, continuous positive airway pressure (CPAP) has demonstrated excellent efficacy in the treatment of patients with OSA, with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation improves anatomic and neuromuscular pathology. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of OSA with hypoglossal nerve stimulation. A meta-analysis by Gillespie and colleagues demonstrated clinically significant decreases in observed mean apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) scores, as well as improvements in quality-of-life scales. The authors reported that hypoglossal nerve stimulation was found to be safe and effective in a subset of patients with OSA who have failed CPAP with evidence of nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32 kg/m2. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment for patients with moderate to severe OSA who are intolerant or unable to achieve benefit with CPAP. The records provided for review document that this patients AHI is less than 20 and he had a BMI of 28 kg/m2. The records fail to include documentation that meets the requirements for the requested Inspire device. Based on the available documentation, the requested Inspire device (hypoglossal nerve stimulator) is not medically necessary for 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 otolaryngology 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

A 61-year-old female enrollee has requested bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient had documented a BMI greater than 35 last year with a weight of 206 pounds and with a BMI of 34.7 thereafter (2 pounds away from a BMI of 35). She also had significant co-morbid conditions including hypertension and secondary cardiovascular disease. The patient had failed prior dietary efforts, completed a multidisciplinary evaluation and was determined to be an appropriate candidate for bariatric surgery. The submitted evidence demonstrates the patient had clinically severe obesity and her BMI rounded to 35, which was the number used by the surgeon and evaluation team to determine her appropriateness for weight loss surgery. All told, the lap band procedure was medically appropriate and necessary for this patient who was unlikely to achieve adequate weight loss results without surgical intervention.