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

Nature of Statutory Criteria/Case Summary: An enrollee has requested modafinil for treatment of the enrollee, who has a history of an anoxic brain injury.  Findings: The physician reviewer found that the submitted documentation supports the requested medication in this patients case.  This patient has had severe traumatic brain injury and has major neurologic deficits.  His medications have caused fatigue, and modafinil has alleviated that.  As a result, he has been more able to participate in therapies, as evidenced by his decline once modafinil was discontinued.  Kaiser and colleagues performed a study of modafinil in post traumatic brain injury fatigue.  The authors noted that excessive daytime sleepiness improved significantly in patients with traumatic brain injury who were treated with modafinil, compared with the placebo group.  There is sufficient support for the requested medication in this patients case.  All told, modafinil 200 mg is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old female who apparently has discrete spots of vitiligo of the hands, trunk, and face. Treatment with topical medications including Elocon, Protopic, and Temovate has been ineffective. A request for authorization for treatment with ultraviolet blue light therapy has been denied by the Health Plan on the basis the requested therapy is not medically necessary for treatment of the patients condition.Ultraviolet blue light therapy is an accepted therapy for treatment of vitiligo. However, the submitted documentation does not indicate the extent, severity, and location of the patients vitiligo. As such, there is no evidence the patients condition has resulted in a functional impairment thereby necessitating ultraviolet blue light therapy. Based upon the information provided, there is no medical justification for ultraviolet blue light therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested ledipasvir/sofosbuvir (Harvoni) 90-400 mg for medical treatment of her chronic hepatitis C genotype 1a.  Findings:  Two physician reviewers found that 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 regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related comorbid conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. Additionally, treatment of patients before their condition progresses to F3 or F4 fibrosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni 90-400 mg is medically necessary for treatment of this patient hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested authorization and coverage for EBCT for evaluation of his heart disease.Reviewers' Findings:  The three physician reviewers found that EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a standard of care modality such as treadmill stress testing. EBCT is also not a medically acceptable substitute for coronary angiography. The use of EBCT in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 33-year-old male with degenerative disc disease. He has had a positive discogram at L4-5 and L5-S1. His provider is recommending a two-level artificial disc replacement at these levels. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There is no data to support such a procedure. There are no known outcomes at two years or more. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, I have determined the requested procedure 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.Physician 2: The patient is a 33-year-old male with two-level degenerative disc disease at L4-5 and L5-S1. The patient has failed conservative management. A two-level disc replacement has been recommended. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, I have determined the requested procedure 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.Physician 3: The patient is a 33-year-old male with degenerative disc disease. He is seeking authorization for two-level artificial disc replacement. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding artificial disc replacement is based upon short-term follow-up in one study. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. There is no evidence for reduced long-term adjacent level disease progression compared to fusion. There are no studies that indicate long-term superiority over fusion. Artificial disc replacement is considered experimental and there is no evidence it is superior to available standard treatment. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested for the use of recombinant human bone morphogenetic protein-2 for thoracic spinal fusion for treatment of the enrollees broken back and neck.   Findings:  Three physician reviewers found that the use of BMP in any procedure other than lumbar spine fusion is novel and is not widely utilized. There may be growing support for its use, but it has not been substantiated by any scientific studies nor compared to standard auto-graft procedures. Therefore, there is insufficient data demonstrating that the use of BMP for thoracic spine surgery was likely to result in a superior clinical outcome in this case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old male who has psoriasis and psoriatic arthritis. Methotrexate, cyclosporin, Soriatane, UVA, and UVB treatments did not result in improvement of the patients psoriasis. Enbrel 25 mg twice a week for 10 months resulted in significant improvement of the arthritis. Initially, the psoriasis improved. Recently, however, new psoriatic plaques have appeared. The dermatologist recommended increasing the patients Enbrel prescription to 50 mg twice a week. The patients rheumatologist has been treating the patient with methotrexate, which has reportedly been ineffectual for the patients psoriasis. The patients psoriasis is worsening. A long list of systemic treatments have not helped in the past. Response to treatment in psoriasis, as in many other medical conditions, may vary from patient to patient. In this patients case 25 mg of Enbrel twice a week is not presently sufficient. Therefore, it is medically indicated and appropriate to increase the Enbrel dosage to 50 mg twice as long as there is not an increased risk. This patient does not appear to be at risk if the dosage is increased. Furthermore, the proposed dosage of 50 mg twice a week is recommended by the manufacturer as well. Based upon the information set forth above, I have determined the requested dosage increase is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees delays in expressive language skills.  Findings:  The physician reviewer found that the current medical evidence supports the requested speech therapy services in this patients case. As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Per Nelson and colleagues, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school age.  Thus, speech and language delay must be taken seriously in young children, as the long-term consequences may be substantial.  Law and colleagues noted that approximately 6% of children have speech and language difficulties.  The authors noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. This patient has expressive language delay, negatively impacting his ability to communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 32-year-old transgender male to female with history of gender dysphoria, and cross-gender hormone treatment. The patient has been taking cross-gender hormone therapy since 2005. The patient has symptoms of persistent anxiety, depression, agoraphobia, and overall distress. The patient reports that consistently being mis-gendered due to the presence of facial hair exacerbates her symptoms of gender dysphoria. The patient was referred for gender affirming laser facial hair removal. Guidelines for the medical necessity of facial feminization surgery (FFS) from World Professional Association for Transgender Health (WPATH) provided guidance on gender reaffirming procedures. On the classification of laser hair removal, the WPATH states that, In addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. This patient is noted to have a history of symptoms of persistent anxiety, depression, agoraphobia, and overall distress due to being mis-gendered on the basis of the presence of facial hair. Based on these findings, laser removal of facial hair is medically necessary for treatment of this patients gender dysphoria.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee requested authorization and coverage of lumbar epidural injections. The Health Plan denied the request indicating that the requested injections are not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested injections are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 14-year-old male enrollee have requested sub-acute residential services for the treatment of the enrollees biochemical abnormalities. Findings:  The physician reviewer found that although the patient was admitted to a sub-acute residential facility, there are no notes indicating the patients mental status examination nor is there any type of psychiatric evaluation done by the facility staff for that date of service.   There is also no evidence that the patient was seen by a psychiatrist while at the facility. The documentation does not support the need for the sub-acute residential level of care. The services at issue were not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female has requested coverage for radiofrequency ablation for treatment of her metastatic leiomyosarcoma.  Findings:  Two physician reviewers found that this patient has metastatic disease involving her lungs, bone and liver. While she has undergone radiofrequency ablation of the bony site of disease, it appears as though she has recurrence.  She has had stable disease over the period of 10 months in all sites and remains asymptomatic. Therefore, given that the hepatic lesion is asymptomatic, is not progressing in comparison to either the June 2011 or January 2011 study, and she has multiple other sites of metastatic disease, radiofrequency ablation is unlikely to provide any significant benefit compared to her current systemic therapy. Given the lack of treatment plan to specifically target the bone and pulmonary lesions, ablative therapy for a single site of metastasis is unlikely to provide any significant benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc left knee injections. Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient reports persistent pain despite a history of three surgical procedures and physical therapy. There is MRI evidence of osteoarthritis of the lateral compartment. The provider has recommended viscosupplementation along with other conservative treatment including icing, splinting, taking Tylenol, and restricting activities, with the objective of delaying total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc left knee injections are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Guardant360 CDx test. Liquid biopsy for next generation sequencing is reserved for patients when there is insufficient tissue at biopsy or in the event of recurrence (Olson; Bettegowda, et al.). Cells from tumor are detected in the blood and used for sequencing, but there is a risk of sequencing normal tissue. This patient presented with a diagnosis of metastatic colorectal cancer. The patients provider recommended analysis with Guardant360 CDx testing. When this patient underwent liquid biopsy with Guardant360 CDx test, there was a lack of evidence of disease on imaging on positron emission tomography (PET) or computed tomography (CT) scan to support an indication for additional testing. In this clinical setting, there is a lack of data supporting a clinical role for Guardant360 CDx testing for evaluation and treatment planning. Therefore, the Guardant360 CDx test was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 31-year-old male enrollee requested a sleep study (polysomnography) for medical evaluation of the enrollees sleep disorder. Findings:  The physician reviewer found that based on review of the available records, the patient does meet the criteria for a sleep study. The patient does have symptoms suggestive of sleep apnea including loud snoring, non-refreshing sleep, and excessive daytime somnolence. In addition, the patient was noted to have a family history of obstructive sleep apnea. However, due to the need to evaluate the patient for sleep apnea, a home study would have been adequate. Golpe and colleagues concluded that home sleep studies are a viable form of diagnosing sleep apnea/hypopnea syndrome while polysomnography should be reserved for patients with inconclusive home studies. All told, the scientific data does not support the medical necessity of the polysomnography.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female with left breast cancer diagnosed in February 2005. The patient has had a left maxillary sentinel node biopsy, which was negative. The patient is scheduled to have a left mastectomy and tram-flap reconstruction. Mammogram of the right breast performed in March 2005 showed a few benign calcifications. Ultrasound of the right breast performed in March 2005 was negative. The patients surgeon has requested a MRI of the right breast indicating the patients breast tissue is dense and nodular, and if the patient does have cancer in the right breast it will change the surgical management. The Health Plan has denied authorization for the requested MRI on the basis it is not medically necessary.Review of the current medical literature reveals there is no disagreement that MRI is more sensitive than mammography or ultrasound in detecting breast cancer. In high-risk patients, MRI has been shown to find breast cancers when mammography has been negative. Patients who have had a prior breast cancer are in a higher risk group for another breast cancer than the general population. The data shows 7% of women who had a prior breast cancer were found to have an occult cancer by MRI (Morris, et al.). Many of the cancers detected by MRI were ductal carcinoma in situ (DCIS). Though the submitted literature indicates the clinical value of a finding of DCIS is unproven, a significant percentage of DCIS progresses to invasive cancer. The detection of DCIS is not insignificant since patients with DCIS are treated with surgical resection and often radiation.The patient in this case is considered to be in a higher risk group than the general population. The patients surgeon has ordered the MRI on the basis the results of the test may possibly alter the patients treatment plan. The proposed screening MRI of the patients right breast is medically appropriate and indicated. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Reclast infusion for the treatment of her osteopenia. Findings:  The physician reviewer found that the patient began taking Fosamax in addition to calcium and vitamin D to protect from osteoporosis. According to a note, there was some apparently minor discomfort with ingestion. The patient is interested in yearly Reclast infusion as an alternative. Her last DEXA scan done noted normal femoral neck density and modest osteopenia of the L-spine with T-score of 1.5. This is very mild compared with age matched controls. The Health Plans criteria are appropriate. Reclast infusion is not medically indicated for this patient.