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

The enrollee requested authorization and coverage, and reimbursement, for percutaneous tibial nerve stimulation. The enrollee has urinary urgency, frequency, and nocturia. He has decreased consumption of caffeine, spicy foods, citrus, and alcohol. He has been receiving percutaneous tibial nerve stimulation to help with his bladder control. His physician reported 100 percent improvement in overactive bladder symptoms after completing percutaneous tibial nerve stimulation for 12 weeks. There is evidence in the peer-reviewed literature from randomized trials supporting the effectiveness and impact of posterior tibial nerve stimulation in those with urinary urgency and frequency. However, most trials have a small number of participants with a short term follow-up. Only one open label trial has a 36-month follow-up. Professional society guidelines for overactive bladder report clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first line therapy to all individuals with overactive bladder. The guidelines rate percutaneous tibial nerve stimulation as a recommended third line therapy. This enrollee is an acceptable candidate for percutaneous tibial nerve stimulation. Final Result: Two of the three reviewers determined that the requested services were not likely to have been, and are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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

The enrollee is requesting authorization and coverage for the VenaSeal vein closure procedure. The enrollee has had worsening, bulging varicose veins over the last ten years. Symptoms include itching, tightness, swelling, and discoloration, with symptoms worse on the right side than on the left. A progress note included a diagnosis of bilateral varicose veins. A progress note from a subsequent visit reported compression stocking and leg elevation interventions have not been successful. The providers recommendation was for venous ablation, VenaSeal, or sclerotherapy. In the context of unsuccessful conservative measures, including lower extremity elevation and compression stockings, the use of endovenous technology, including VenaSeal, is likely to be more beneficial than previously tried conservative attempts at symptom relief. This enrollee has tried and failed such conservative therapies, with a clinical result that is unsatisfactory. Therefore, this enrollee is an appropriate and suitable candidate for such technology. Final Result: Two of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a procedure to surgically remove the varicose veins. The enrollee has bilateral lower extremity varicose veins. The record indicates she is experiencing a sense of swelling, heaviness, and pain in her legs when she tries to work out. Her symptoms are advancing despite wearing compression hose. The pain is interfering with her ability to work and becomes so intense as to make her physically ill. Findings: . Her physician documented a cluster of moderate-sized varicose veins on the medial aspect of her right leg, varicosities in the proximal medial thigh with vulvar varicosities, and varicosities measuring over 6 mm in size on the medial aspect of the left leg and thigh. Ankle swelling is minimal. She has no reflux in the greater saphenous vein. The physician suspects some pelvic reflux due to the proximal medial thigh varicosities. Notes indicate the possible need for future intervention for the pelvic reflux. However, the physician wants to treat only the symptomatic veins with stab phlebectomies. According to the medical literature, the indications for ambulatory phlebectomy include asymptomatic varicose veins for cosmetic purposes, symptomatic varicose veins not responding to conservative treatment, and enrollees with complications of varicose veins, such as superficial thrombophlebitis, recurrent thrombophlebitis, and bleeding. Stab phlebectomy involves the removal of varicose tributaries. It is a well-described and standard approach in these settings. Based on the enrollees physical examination, her condition was debilitating due to bulging veins and throbbing that made her physically ill and faint. She had to wear compression tights all year round.  The literature supports the performance of the requested procedure for enrollees such as this one as she did not have reflux, but had objective findings. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Vascular 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Amniox Neox grafting. Findings:  Three physician reviewers found that plantar fasciitis is a self-limiting condition and studies show that most cases resolve completely with non-surgical treatment. After non-surgical techniques have been used, procedures that create an acute inflammatory reaction to reinitiate the failed healing process can be utilized. Surgical procedures include Topaz technique, platelet rich plasma injections, and traditional surgical fasciotomies both partial and total. In this case, the surgery performed provided the beginning of a new healing process for the plantar fasciitis. As such, it was not necessary to include another healing process with Amniox grafting at the same time. As such, the Amniox Neox grafting provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the services at issue were 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: All three physician reviewers are board certified in podiatry 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 29-year-old female enrollee has requested for physical therapy for treatment of her condition. Findings:  The physician reviewer found as per the ISSVD Vulvodynia Guideline, physical therapy also may decrease pain with intercourse and gynecological examinations. Physical therapy treatment techniques include internal (vaginal and rectal) and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, instruction in dietary revisions, therapeutic ultrasound, and home vaginal dilation. The proposed physical therapy treatments in this case have the support of nationally recognized medical specialty organizations.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Epclusa 400 mg-100 mg and ribavirin 1200 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees medical condition.According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with the medical condition should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients, and those who failed peg-interferon and ribavirin. Both groups were studied in the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% in treatment-naive patients and 90% in treatment-experienced patients (Foster, et al). The use of ribavirin is recommended by the guidelines in patients with the Y93H mutation, which the patient has. AASLD/ISDA guidelines state If the Y93H substitution is identified, a different regimen should be used, or weight-based ribavirin should be added as an alternative option.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Epclusa 400 mg-100 mg and ribavirin 1200 mg for 12 weeks is supported as medically necessary for the treatment of this 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 reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male with morbid obesity and chronic obstructive pulmonary disorder (COPD). The patients pulmonologist has requested authorization for a power-operated vehicle (POV) for the patient. The pulmonologist states the patient has shortness of breath while lying down and walking short distances. The patient was noted to have oxygen desaturation, but not low enough to qualify for supplemental oxygen. The pulmonologist was also working up the possibility of interstitial lung disease. A letter from the patients primary care physician restated the patients medical causes for shortness of breath, which included morbid obesity (BMI greater than 60), emphysema, coronary artery disease, and advanced arthritis. Spirometry from 12/14/04 interpreted by the pulmonologist noted no change in the FVC or FEVI and no evidence of obstruction by possible restrictive lung disease. According to notes from an office visit on 12/14/04, the patient is to be evaluated for bariatric surgery.The Health Plan has denied authorization for the POV indicating the patient should undergo evaluation by a physiatrist.The patients pulmonologist and PCP both recommended use of a POV in order to alleviate the patients shortness of breath. There are multiple medical reasons for the cause of the dyspnea including COPD, coronary heart disease, possible interstitial lung disease, and deconditioning associated with morbid obesity. The Health Plan has denied coverage for a POV indicating the patient was not adequately evaluated for the equipment. The Health Plan is correct. The patient should undergo formal evaluation by a physiatrist, ideally a pulmonary rehabilitation medicine specialist. The submitted documentation does not demonstrate a POV is medically necessary at this time. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old enrollee has requested for a laparoscopy for evaluation of his gender identity disorder. Findings:  The physician reviewer found that the persistent Mullerian duct syndrome (PMDS) is a rare form of inherited male pseudohermaphroditism characterized by the presence of Mullerian derivatives in otherwise normally masculinized XY males. The condition is due to a deficiency of anti-Mullerian hormone. Unless an elder brother has been diagnosed with the condition and there is appropriate suspicion raised, the persistence of uterus and tubes is discovered in a patient undergoing surgical repair of cryptorchidism or inguinal hernia. Two anatomical forms of PMDS have been described, and patients will only present with these findings on examination. The association of unilateral cryptorchidism, with one testis located in the abdomen and the other in a contralateral hernia, characterizes the most common form. One testis descends into the scrotum, and the ipsilateral uterus and fallopian tube either enter the inguinal canal, a condition known as hernia uteri inguinalis, or can be dragged into it by gentle traction, bringing the contralateral testis and fallopian tube in their wake. Often, no traction is necessary, because the contralateral testis is already in the hernia sac. Transverse testicular ectopia, as this condition is called, is extremely common in PMDS. More rarely, in a second clinical presentation, PMDS takes the form of bilateral cryptorchidism. The uterus is fixed in the pelvis, and both testes are embedded in the broad ligament in the abdomen. These clinical variants are not determined genetically and may occur within the same sibship.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Taltz. Psoriasis is often a chronic condition with periods of remissions and exacerbations. Indications for a biologic agent such as Taltz requires current documentation of moderate-to-severe psoriasis or active psoriatic arthritis. The records provided for review do not support a current indication for treatment with Taltz. The patients last documented evaluation was in 2019 for psoriasis of the skin. There is a lack of report of any exacerbations, treatments, and/or physical examinations for 2020 or 2021. Per the joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF), there are many factors that must be considered by a provider prior to recommending treatment with Taltz and regular follow-up with the treating provider is essential. All told, the requested Taltz is not medically necessary for treatment of this patient. 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 dermatology with subspecialty certification in dermatopathology 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 50-year-old female enrollee has requested for portable oxygen for home use for treatment of her headaches.  Findings:  The physician reviewer found that there is limited evidence sustaining the positive impacts of oxygen for the treatment of migraine. To date, there are inadequate scientific data in terms of large, randomized clinical trials with long-term follow-up that demonstrate the effectiveness of oxygen in improved health benefits in patients with migraine. In addition, this patients records do not document that she has exhausted standard therapies including beta blockers, calcium channel blockers, and antidepressant medications.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Amerge 27 tablets per 30 days for treatment of her migraine.  Findings:  The physician reviewer found that based on review of the available records, this patient has a long history of migraine. Given the high frequency of headaches, her condition is consistent with chronic migraine. She is not on reportedly on preventive therapy, and is noted to be using multiple acute medications, including up to 27 Amerge per month. Use of abortive medications more than two days per week on average can be associated with development of medication overuse headache. The American Migraine Prevalence and Prevention Study demonstrated that, transformation is most likely to occur with 5 days of butalbital use per month, 8 days of opioid use per month, 10 days of triptans or combination analgesic use per month, and 10 to 15 days of non-steroidal anti-inflammatory use per month. Acute migraine treatment should be limited to 2 or fewer days per week. Optimal therapy should involve assessment of factors such as obesity, possible sleep apnea, and medication overuse, and treatment along with refinement of preventive therapy. All told, the records support the medical necessity of Amerge up to two tablets per day, two days per week, for a total of 16 tablets per month, for treatment of this patients medical condition. Therefore, a portion of the requested medication dosage is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture/acupressure, once per week, trigger point injections, medial branch blocks (MBBs), subacromial bursa injections, Percocet 10 mg, three times per day, oxycodone-acetaminophen 10-325 mg, every eight hours, pentoxifylline XR 400 mg, twice per day, Flexeril 10 mg, as needed, once per day, Neurontin 300 mg, three times per day, and Lyrica 50 mg, every 12 hours. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services and requested medications. This patient has requested an array of therapies without proper clinical basis and against clinical practice guidelines. He has several red flags which make prescribing chronic opiates problematic. These include the use of cannabis, a past history of alcohol abuse, and a history of depression. In this setting, there is a lack of support for medication management with opiates and benzodiazepines. Additionally, therapeutic plans which include injections should be ordered by medical providers. The documentation does not indicate that the requested injections have been recommended by the patients providers. Thus, the records do not support the medical necessity of the requested injections in this setting. With regards to MBBs and acupuncture, there is no note from his last primary care provider or last pain management provider recommending either of these interventions. There are a lack of physical examination findings that support facet joint syndrome. In sum, the requested acupuncture/acupressure, once per week, trigger point injections, MBBs, subacromial bursa injections, Percocet 10 mg, three times per day, oxycodone-acetaminophen 10-325 mg, every eight hours, pentoxifylline XR 400 mg, twice per day, Flexeril 10 mg, as needed, once per day, Neurontin 300 mg, three times per day, and Lyrica 50 mg, every 12 hours are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services and requested medications 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg tablets. Based on the available records, this patient has alopecia areata that has responded well to treatment with Xeljanz. Prior treatment has included finasteride, prednisone, and methotrexate. Available treatment options for patients with alopecia areata are limited, especially for those with multifocal involvement, where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy, and conventional immunosuppressants are oftentimes inadequate. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for the treatment of alopecia areata. In one open-label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring (Jabbari, et al.). Similarly, Liu and colleagues found that 77% of patients achieved a clinical response, and 58% had an estimated 50% change in SALT score. Overall, the current data demonstrates that Xeljanz is safe and effective for use in this patients clinical setting. Therefore, the requested Xeljanz 5 mg tablets 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 dermatology with subspecialty certification in dermatopathology 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.