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

An enrollee has requested authorization and coverage for Brilinta 90 mg tablets. The submitted documentation supports that the requested medication is medically necessary. Records reflect that the patient had a recent acute coronary syndrome that was treated with coronary stent placement. In this setting, treatment with a more potent P2Y12 inhibitor, tigacrelor (Brilinta), has been shown to improve outcome over less potent P2Y12 inhibitors such as clopridogrel (Plavix). Treatment with Brilinta in this setting is reasonable, appropriate, and considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations also consider this therapy appropriate. Accordingly, Brilinta 90 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in cardiovascular disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested post-acute inpatient rehabilitation services for treatment of his medical condition status post intracranial hemorrhage.  Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) guidelines suggest that patients may be appropriate candidates for continued inpatient rehabilitation when they are reasonably expected to make measurable and practical functional gains within a reasonable period of time. It is also assumed that these patients would not progress at a similar rate in a less intensive rehabilitation setting. This patient's progress appears to haved slowed considerably and it is likely that any future gains achieved in a post-acute inpatient rehabilitation program would be similar to those obtained in a less intensive setting. Approximately three months post intracranial hemorrhage, the records provided for review indicate that he had begun to plateau from a functional perspective. While the patient may continue to demonstrate recovery of function over time, it is likely that the recovery curve will be gradual. In light of this, as well as the paucity of randomized clinical trials demonstrating therapeutic benefit of the requested services in this setting , inpatient rehabilitation services are not likely to result in greater or more rapid functional improvement than a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested psychiatric residential treatment services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that neither the patients history nor her treatment course identified any treatment needs that could not have been addressed on a purely outpatient basis. For example, the patients response to stopping Zoloft and beginning Lexapro could have been monitored during outpatient therapy. Similarly, the patients history of unsuccessful personal relationships and overeating did not demonstrate a medical need for residential care. While these problems are relevant to the patients treatment, there is no evidence to suggest that these issues could not have been successfully addressed in an outpatient treatment program. A review of all the information submitted does not demonstrate any evidence establishing that residential services were medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a biological knee replacement for treatment of her right knee osteoarthritis.  Findings:  The physician reviewer found that biological knee replacement is a term utilized by orthopedic surgeons advocating the methods of meniscus transplantation, application of articular cartilage paste grafting and ligament replacement in an effort to delay total joint arthroplasty. It is described as any combination of meniscus transplantation, application of articular cartilage stem cell paste grafting or ligament reconstruction. These methods utilize allograft material. The issue to be decided in this case is whether it is medically necessary for this patient to receive a biological knee replacement, i.e., autologous chondrocyte implantation through cartilage paste and meniscal replacement. The patient appears to have bicondylar tricompartmental degenerative osteoarthritis. At age 57, the use of the techniques described above is supported by level three and level four studies which are considered lower level evidence. Such studies are not adequate to support biological knee replacement over conservative care with subsequent total joint replacement. The patients current management reflects the standard of care for this patients disorder. The use of biological knee replacement for treatment of this patients condition remains the subject of debate. The requested procedure has not been proven in the currently available peer-reviewed medical literature to be safe or efficacious for the treatment of this patients medical condition. Therefore, the  denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of his medical condition. Findings:  Two physician reviewers found that radiofrequency ablation is likely to be more beneficial for treatment of the enrollees medical condition. The peer-reviewed literature supports the efficacy of radiofrequency ablation in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. Tzaan and Tasker performed a retrospective study to assess the value of percutaneous radiofrequency facet rhizotomy. The authors concluded that the procedure is simple and safe in patients with disabling spinal pain that fail to respond to conservative treatment. Per the medical records submitted, imaging is significant for multi-level spondylosis. The physical exam is also significant for facet mediated pain. The provider documents that the patient has failed conservative treatment. In addition, the records document 90% pain relief with diagnostic medial branch blocks. Therefore, radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are 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 anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary. An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the patient presented for a follow-up targeted left breast ultrasound and left breast diagnostic mammogram with tomosynthesis. A previously seen nodule medially in the posterior left breast was not seen on the diagnostic mammogram.  There was no abnormality on the ultrasound. The evaluating provider reported that the nodule may have been a cyst which resolved in the interval. The assessment was BI-RADS category 1, negative. Routine screening mammogram was recommended in 12 months. The Health Plan denied reimbursement for the digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two physician reviewers determined that the service 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 overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

A 55-year-old female enrollee has requested a referral to a sarcoma specialty center for the treatment of her uterine leiomyosarcoma. Findings:  The physician reviewer found that there certainly is value to consulting a specialist.  In rare tumors such as this, there is often no consensus as to the appropriate treatment plan, especially in the adjuvant setting. If the out-of-network sarcoma specialist is able to provide the patient the opportunity to participate in a treatment strategy (such as a clinical trial) that cannot be provided in-network, then the treatment should be covered out of network.  If not, the patient should be covered for her initial out-of-network consultation as well as for further consultations with the sarcoma specialist as needed, such as in the setting of a recurrence, or at times when treatment decisions may need to reviewed in response to changes in her clinical course.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested the medications Abraxane and Avastin for the treatment of her metastatic melanoma. Findings:  Two physician reviewers found that there are few therapies available for patients with metastatic melanoma and no treatment has been found to be curative. In this clinical setting, it is appropriate to devise a reasonable treatment plan based upon the available medical data and experience. There is increasing published data on the use of carboplatin and paclitaxel in the treatment of metastatic melanoma. These agents have been found to be well-tolerated with good clinical activity. Extrapolating from this experience, clinicians have substituted Abraxane for paclitaxel. This albumin bound form of the native paclitaxel has been found to be both more tolerable and effective than the native compound in Cremophor. There has been promising phase II data regarding the use of this agent in metastatic melanoma. Avastin is a drug of interest in many tumor types. It is of great interest in melanoma, due to the highly vascular nature of these tumors. Phase II data evaluating Avastin in combination with carboplatin and paclitaxel, as well as with Abraxane are available. These studies have shown promising activity with acceptable toxicity. This particular patient had an excellent clinical response to this combination therapy, demonstrating the value of this regimen in this case. In summary, there is no standard therapy for this patient. Current research is focused on the agents at issue. The phase II data for these agents is good in a very difficult to treat disease (Perez and colleagues and Hersh and colleagues). In addition, this patient experienced a good response to this chemotherapy regimen to date.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nexium and Benicar. Findings: The physician reviewer found that the request for Nexium and Benicar has been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient has increased cardiovascular risk, cerebrovascular disease and both hypertension and acid reflux that have been managed long-term with Benicar HCT and Nexium. In this circumstance, continued use of these medications as the patient transitions to a new primary care provider is reasonable and appropriate. Since a temporary lapse in these medication may be severely detrimental to the patients health continued coverage of her medications is medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  2/3 of the physician reviewers found that review of the current literature indicates that use of hypoglossal nerve stimulation in treatment of OSA shows promise. However, criteria for the use of this therapy includes that patients have moderate to severe OSA with an AHI between 20 and 60, BMI of less than 32, and failure of trial of CPAP therapy. This patient has an AHI of 76.7 which is greater than the U.S. Food and Drug Administration (FDA) criteria of less than 60 and greater than 50, which is used for most study criteria. In addition, the medical records provided do not demonstrate the patient has failed treatment with standard therapies including CPAP. As such, this mode of treatment is not medically indicated for this patient. Overall, there remains a need for further study with comparison of outcomes between hypoglossal nerve stimulation and standard CPAP and surgical therapies. For these reasons, the requested implantation of a hypoglossal nerve stimulator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the requested service is 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. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in sleep 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epoprostenol (Veletri) infusions (HCPCS J1325). This patient has severe refractory Raynauds phenomenon with digital ischemia and ulcerations due to systemic sclerosis. The patient has failed multiple standard therapies and has digital ischemia with necrosis. Veletri has been demonstrated to be effective even in patients who have been refractory to other therapies. This patient has demonstrated a positive response to Veletri in the past. Cruz and colleagues reported that the available evidence supports intravenous (IV) Veletri for treatment of severe Raynauds phenomenon in patients refractory or intolerant to standard therapies. Given these findings, the requested epoprostenol (Veletri) infusions (HCPCS J1325) are 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 internal medicine with subspecialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male enrollee has requested allograft transplantation for treatment of his deficient hyaline cartilage on medial condyle.  Findings:  Two physician reviewers found that given the radiographic findings of joint space narrowing and degenerative osteoarthritis, this patient is not an ideal candidate for allograft transplantation at this time. The evidence based guidelines suggest normal joint space and no presence of arthritis or inflammation in the joint. The x-ray report taken together with the clinical examination description of tenderness along the osteophytes, does not satisfy these criteria for the proposed procedure. Thus, the requested osteochondral allograft is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Cosentyx. Pityriasis rubra pilaris is an inflammatory dermatosis of unknown etiology. The typical morphologic features of pityriasis rubra pilaris are erythematous squamous salmon-colored plaques with well demarcated islands of unaffected skin. Disease management of pityriasis rubra pilaris includes systemic retinoids, methotrexate, and other immunosuppressive agents, as well as ultraviolet (UV) light therapy. Cosentyx has been demonstrated to provide positive results in the treatment of pityriasis rubra pilaris in recent case reports. The records indicate that this patient has tried and failed treatment with current first-line therapies including topical steroids, prednisone, and acitretin. Thus, the requested Cosentyx is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that Cosentyx is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Supprelin LA 50 MG subcutaneous implant. Researchers note that puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria. The authors conclude, A treatment protocol including puberty suppression leads to improved psychological functioning of transgender adolescents. While enabling them to make important age-appropriate developmental transitions, it contributes to a satisfactory objective and subjective well-being in young adulthood. The World Professional Association for Transgender Health (WPATH) states, Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. Some children may arrive at this stage at very young ages (e.g., 9 years of age). Studies evaluating this approach only included children who were at least 12 years of age. Two goals justify intervention with puberty suppressing hormones: (i) their use gives adolescents more time to explore their gender nonconformity and other developmental issues; and (ii) their use may facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue sex reassignment. In this case, the patient has a diagnosis of gender dysphoria with a providers statement that the requested implant is medically necessary. Therefore, Supprelin LA 50 MG  subcutaneous implant is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested implant 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 with expertise in transgender health 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.