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

The parent of a five-year-old female enrollee has requested Genotropin for treatment of the enrollees Prader-Willi syndrome. Findings:  The physician reviewer found that this patient has Prader-Willi syndrome. Although her height is currently within normal limits, she is likely to have at least some degree of impaired growth hormone secretion. This contributes to abnormal body composition and energy expenditure and abnormal carbohydrate and lipid metabolism. Based on the physicians letter of appeal, there is evidence of panhypopituitarism. Thus, growth hormone therapy is medically indicated for this patient, even if she has not yet demonstrated fall-off in growth. Growth hormone treatment for children with Prader-Willi syndrome has been shown to improve linear growth, promote growth of lean body mass, decrease fat mass, and improve cardiovascular risk factors.  Complications of growth hormone therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, growth hormone therapy is considered to be generally safe in this population.  All told, Genotropin is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Besremi injections. The U.S. Food and Drug Administration (FDA) describes Besremi, ropeginterferon alfa-2b, as an interferon alpha-2b that is indicated for the treatment of adults with polycythemia vera. In a Phase III, randomized controlled trial, Gisslinger and colleagues reported that ropeginterferon alfa-2b was effective in inducing hematological responses that continued to increase over time with improved responses compared with hydroxyurea at 36 months. The authors concluded that considering the high and durable hematological and molecular responses and its good tolerability, ropeginterferon alfa-2b offers a safe long-term treatment option with features distinct from hydroxyurea. Given that current medical literature supports the use of Besremi in this clinical setting without requiring the failure of prior therapy, the requested services are medically indicated. Therefore, Besremi 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 internal medicine with sub-specialty certifications in medical oncology and in 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: Overturned

A 36-year-old female enrollee has requested a CPAP machine for treatment of her sleep apnea.  Findings:  The physician reviewer found that generally, initiation of CPAP is indicated if AHI is greater than 5, and the patient has several clinical sequelae, such as excessive daytime sleepiness, impaired neurocognitive functioning, mood disorders, insomnia or cardiovascular disease. Although this patient had an AHI of 4.3, her episodes were rather severe during REM sleep (AHI of 15.2 with desaturations to 89%).  Additionally, the submitted documentation indicates that the patient may also have had respiratory effort related arousals which could also be contributing to her objective and subjective sleepiness. In this patients case, she has a history of poor concentration and excessive daytime sleepiness. A CPAP machine is likely to benefit this patients symptoms. All told, the submitted documentation demonstrates the medical necessity of the requested CPAP machine for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the notes indicate that anxiety was a significant complicating factor in treatment. The patient was on several different antidepressants. Additionally, he underwent two electroconvulsive treatments in the past, but reportedly was unable to tolerate this treatment. Details of past treatments in terms of compliance, length, dose, side effects and response are not noted in the record. Details of the electroconvulsive therapy treatments in terms of electrode placement, dosing, side effects and adjunctive medications administered were not provided. Details regarding past trials are lacking. His condition has been complicated by comorbid anxiety which evidently did not improve significantly. There is a lack of data available regarding the efficacy of transcranial magnetic stimulation in patients with comorbid anxiety disorders. Additionally, the patient did not have an adequate course of electroconvulsive therapy, which is recognized by the American Psychiatric Association as the most effective treatment for depression. The record fails to establish whether mitigating variables such as comorbid substance abuse and/or Axis II disorders and psychosocial stressors have been investigated and addressed.  Thus, transcranial magnetic stimulation provided during the said timeframe was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested an MRI scan (CPT code 77058) for evaluation of her ductal carcinoma in situ.  Findings:  Two physician reviewers found that the patient had an MRI of the breast which demonstrated a questionable lymph node of the right axilla, which was enhancing.  A fine needle aspiration of the lymph node on the date in question was benign.  A few months later, the patients oncologist requested a six-month follow-up MRI.  Lymph nodes containing tumor cannot be reliably diagnosed at this time with the current contrast agents.  At this time, lymph node staging by MRI is not established in the medical literature.  MRI features of metastatic lymph nodes depends more on size and morphology than on enhancement criteria.  Further, in this patients case, sampling was performed and was determined to be negative.  In this patients case, conventional imaging, such as ultrasound, can be performed.  All told, the requested MRI scan is not likely to be the most efficacious method of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name LoSeasonique tablets. LoSeasonique 20 ug with three-month dosing does not have a comparable contraceptive medication in the same class. In this case, the provider noted that the patient has been treated with medications similar to LoSeasonique with a lack of efficacy or intolerable side effects. However, the patients premenstrual syndrome, dysmenorrhea, depression, and anxiety have all been reportedly improved with brand name LoSeasonique. The American College of Obstetricians and Gynecologists (ACOG) supports treatment with brand name oral contraceptive medications when there are concerns regarding packaging or compliance, or when the name brand product is considered a better choice for the individual patient. Brand name LoSeasonique is a better choice for this patient in lieu of generic formulations as lower estrogen products have fewer side effects, and she has responded well to this medication. All told, the requested brand name LoSeasonique is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mekinist. Findings:  The physician reviewer found that noted in the medical literature, treatment for Erdheim-Chester disease (ECD) is reserved for patients who are symptomatic. This patient reports symptoms including bilateral thigh pain, back pain and abdominal discomfort. Further, the patient is reported to be wild type for BRAF, meaning he does not harbor a mutation limiting treatment options. Treatment with a MEK inhibitor such as Mekinist is considered the standard of care in patients who have a wild-type BRAF. Thus, the requested treatment with Mekinist is supported as medically necessary for treatment of this patients ECD. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Overturned

An enrollee has requested authorization and coverage for Dupixent. The submitted documentation supports the medical necessity of the requested medication. This patient tried and failed topical medications as well as oral steroids. Per the submitted documentation, a treatment trial with tacrolimus ointment was ineffective. Dupixent is the only U.S. Food and Drug Administration (FDA) approved biologic for atopic dermatitis. There is no other FDA approved biologic therapy, and there is no step therapy associated with biologic use for atopic dermatitis. In the setting of moderate to severe atopic dermatitis, the use of Dupixent is medically appropriate when topical medications are ineffective. Therefore, Dupixent is medically necessary 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 dermatology 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for continuation of 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and eight hours per month of clinical team meetings provided. Findings:  The physician reviewer found that there is a strong correlation between treatment outcomes and treatment intensity for children with autism . The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. ABA has been effective for this patient, however she continues to demonstrate maladaptive behaviors that are occurring across multiple environments. Per the progress notes, she has 16 maladaptive behavior goals which she has not met. In addition, her maladaptive behaviors are described as dangerous to herself and others. Based on the documentation submitted for review, 40 hours per week of one-on-one ABA therapy, 16 hours per month of supervision and eight hours per month of clinical team meetings provided  since the beginning of the year and forward was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 LINX esophageal sphincter augmentation device for treatment of the enrollees Barretts esophagus, hiatal hernia, and gastroesophageal reflux disease (GERD). Findings: Two physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). One peer-reviewed journal reported that there are 11 cases of endoscopically-confirmed LINX erosion through the esophagus in the FDA Adverse Events database (Bielefeldt). Additionally, LINX, more than surgical fundoplication, is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX esophageal sphincter augmentation device is not 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 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.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gel One (CPT J7326). Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of positive results with prior Gel One viscosupplementation injections. Furthermore, the patients available treatment options are limited. The requested Gel One injections into both knees is appropriate for management of the patients bilateral knee osteoarthritis. Therefore, the requested Gel One (CPT J7326) injections are medically necessary for 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuous positive airway pressure (CPAP) machine and supplies for treatment of his obstructive sleep apnea (OSA). Findings: The physician reviewer found that the records provided for review document the patient was noted to have an AHI of 7.8. Per the American Academy of Sleep Medicine (AASM) for OSA, this patient meets the criteria for a diagnosis of OSA. The patient has witnessed apneas and the results of the diagnostic home sleep test provided objective measurements of snoring and apneas. The patient is also noted to have had an AHI greater than five, which further supports a diagnosis of OSA. In reviewing current practice guidelines on the treatment of OSA, there is a recommendation that patients with OSA be treated with CPAP as a first-line of therapy. While the records do not indicate that the patient had a co-morbid condition as required by the Health Plan, the current literature and practice guidelines do not require the presence of such co-morbid conditions for treatment with CPAP. Therefore based on current literature the requested CPAP machine and supplies are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested for continuous CEA testing for evaluation of her metastatic breast cancer.   Findings:  Three physician reviewers found that CEA marker has been useful in predicting response. Although CA15.3 is often used in breast cancer, it is not useful in this clinical setting. The CEA is a very useful marker in this patient. The traditional CA15.3 is not useful in monitoring this patients response to therapy. The requested CEA testing is likely to be beneficial for monitoring of this patient, and it is likely to be more efficacious than alternative testing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Myrbetriq 50 mg tablets. Overactive bladder syndrome is defined by the International Continence Society (ICS) and International Urogynecological Association (IUGA) as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. The American Urological Association (AUA) guidelines recommend a stepwise approach to treatment, including behavioral modification and medical management (Gormley, et al.; Lightner, et al.). First-line medical management of overactive bladder includes anticholinergics, such as tolterodine or oxybutynin or the beta-3 agonist mirabegron (Myrbetriq). As noted in the medical literature, Myrbetriq has been shown in multiple prospective randomized trials with large numbers of patients to have equal efficacy to anticholinergic medications treating overactive bladder, but with fewer adverse events. This patient presents with a history of overactive bladder with symptoms including frequency and urgency. Per the medical records reviewed, the patient was previously treated with generic anticholinergic medications without relief of symptoms. The patients provider has recommended treatment with Myrbetriq, which is consistent with the U.S. Food and Drug Administration (FDA) approval and AUA guidelines for use of Myrbetriq. Therefore, the requested Myrbetriq 50 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 urology 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 female enrollee requested cervical disc replacement (discectomy and arthroplasty) with possible allograft for medical treatment of her cervical strain and radiculitis.  Findings:  Three physician reviewers found that cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty material debris are not known at this time. Therefore, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy.