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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the platelet rich plasma and stem cell injections. Platelet rich plasma and stem cell injections are not supported by sufficient clinical evidence for use in this clinical setting. Long-term benefits of platelet rich plasma have not been demonstrated in the knee. Short-term benefits, lasting from six months to over one year, include functional improvement and pain relief. However, these results have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. One study in patients with early arthritis compared the effectiveness of platelet rich plasma with hyaluronic acid injections and reported that platelet rich plasma is promising for less severe early arthritis in patients under 50 years of age, but not for more severe osteoarthritis, especially in older patients. Based on the available evidence, the platelet rich plasma and stem cell injections were not likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy.One reviewer found that the platelet rich plasma injections were likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy, and the stem cell injections were not likely to be more beneficial for treatment of the patients left knee osteoarthritis than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Urgent Care
Decision: Upheld

A 19-year-old female enrollee has requested emergency services for the treatment of her panic attack. Findings:  The physician reviewer found that the patient is a 19-year-old female with diagnosed bipolar disorder, OCD, and a history of anxiety who presented to an emergency department. She presented to the emergency department because she was worried about running out of her previously prescribed medications.  She also felt panic-stricken that particular day. She was told of an easier manner in which to get her refills taken care of and then left the emergency department.  Although the patient was rather anxious, there is no evidence that there was anything emergent in nature related to her seeking refills for her prescription medications such that she would need to use an emergency department for prescription refills.
Appeal type: Experimental/Investigational
Decision: Overturned

A 20-year-old female has requested surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo) for treatment of migraine headache with visual aura.  Findings:  Two physician reviewers found that the medical records document persistent visual migraine aura which caused an inability to read.  She has been tried on multiple medications, without benefit.  The patients provider has recommended surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo).  The requested services are likely to be more effective than other treatment alternatives.  There is adequate support in the current medical literature for the requested services in this patients case.  Trabattoni and colleagues reported an overall improvement in migraine in 89% of patients who underwent the requested surgery.  The study by Khessali and colleagues demonstrated significant resolution of aura at one year following this procedure.  Based upon this patients clinical history and the current medical evidence, the requested surgery (transcatheter PFO/ASD closure and associated intra-cardiac echo) is likely to be more beneficial than other treatment options.
Appeal type: Urgent Care
Decision: Overturned

A 21-year-old male enrollee has requested for emergency services required on an emergent basis. Findings:  The physician reviewer found that the patient developed a non-productive cough and began vomiting. Vital signs revealed a temperature of 99.2, a blood pressure of 132/71, heart rate of 140, respirations of 16, and an oxygen saturation of 99%. Physical examination was significant for enlarged red tonsils without exudate. Cervical adenopathy was present. Heart sounds were tachycardic with pulsus alternans. Lungs were clear, and his abdomen was soft.  The patient was medicated with two liters of normal saline solution and Zofran intravenously. Ibuprofen and Tamiflu were administered orally. The patients heart rate improved to 101 beats per minute.  The provider noted that the patient most likely had the H1N1 influenza, and he was discharged with a prescription for Tamiflu.A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his health in these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous hormone pellet therapy for treatment of the enrollee, who reported fatigue, memory disturbance and insomnia. Findings: All three physician reviewers found that the medical evidence does not support the services at issue in this clinical setting. Testosterone pellets are compounded products which are not produced by any pharmaceutical company and are not approved by the U.S. Food and Drug Administration (FDA). There are many FDA-approved treatments available for menopausal symptoms. However, this patient has not reached menopause. Her hormone testing was normal, with no evidence of perimenopause, and normal testosterone levels. In addition, fatigue and insomnia is multifactorial, and there is no evidence in the record of any evaluation or attempts at therapy other than testosterone pellet implants.  In this case, the patient repeatedly received high doses of testosterone which was likely to cause supraphysiologic levels and potential side effects. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee requested breast magnetic resonance imaging (MRI) for medical evaluation of her nipple discharge.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the diagnostic procedure in this clinical setting. The peer-reviewed literature and practice guidelines support the use of breast MRI in females with BRCA 1 or BRCA 2 gene mutation, personal history of breast cancer, high familial risk of breast cancer and a lifetime risk of breast cancer 20-25%. This patient meets none of the criteria listed above. As such, there is a lack of evidence in the clinical records or applicable practice guidelines to support the use of breast MRI in this clinical setting. All told, the breast MRI performed was not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency neurolysis. The records provided for review do not indicate physical examination findings consistent with facet mediated pain. In addition, the records do not document findings of positive diagnostic facet blocks with anesthetic producing 70% or better pain relief for duration of anesthetic. The current guidelines support radiofrequency neurolysis when there is facet mediated pain and documented series of two diagnostic facet blocks with anesthetic. Researchers reported that radiofrequency neurolysis of the facet joints shows improved pain control for facet mediated pain in patients with low back without radiculopathy. A study found no benefit for radiofrequency neurolysis in patients with low back pain without radiculopathy or facet mediated pain. There was benefit for patients with facet mediated pain. As this patients records do not document facet mediated pain with positive response from diagnostic blocks, the radiofrequency neurolysis was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the radiofrequency neurolysis was 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 service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant gene test. Findings: Three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant gene test was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested authorization and coverage for upper and lower jaw surgery for treatment of the enrollees facial pain, temporomandibular joint (TMJ) pain and shoulder and neck pain.  Findings: The physician reviewer found that the records provided for review document that this patient has been diagnosed with a maxillofacial skeletal deformity. Based on current medical literature, the proposed procedure will result in improved musculoskeletal and dento-osseous relationships. Moreover, the procedure should improve the patients mastication and associated temporomandibular joint as well as associated muscular disorders and symptoms. The proposed surgery is appropriate for the diagnosis of the patients condition, and is within generally accepted standards of medical care in the community. For these reasons, the requested upper and lower jaw surgery is supported as medically necessary for treatment of this patients maxillofacial skeletal deformity.Final Result: The reviewer determined that the requested surgery 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 oral and maxillofacial 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

The patient is a 58-year-old male with a history of snoring, muscular weakness and constant fatigue. He also has some history of coronary artery disease, having had stints placed in the past. Because of his symptoms he was referred to and evaluated by a physician who appears to be a pulmonologist specializing in sleep disorders. His primary care provider referred him to this physician. An overnight oximetry was performed in November 2003 that indicated 407 desaturation events to have occurred during approximately a 10-hour period. Based on this result the patient was prescribed a therapeutic trial of CPAP even before polysomnography was performed. This latter study was recommended or scheduled but apparently never took place. The patient indicates he has been using a CPAP device with great success and relief of his symptoms. He has requested reimbursement for use of the CPAP device. The Health Plan has denied coverage on the basis there was no polysomnography demonstrating medical necessity for CPAP.Based upon the submitted documentation, it does not appear the patient has undergone somnography. A polysomnography is necessary to document the presence of obstructive sleep apnea. If the patient undergoes polysomnography and the results are positive, the patients request for reimbursement for CPAP therapy should be reconsidered by the Health Plan. However, based upon the evidence provided, it has not been established that CPAP therapy was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Aimovig. The enrollee has a ten year history of migraines that sometimes occur every 36 hours. She was seen by her provider for an examination. Her neurological examination was grossly normal. The treatment plan for the migraines included Botox every three months and Imitrex one tablet every four hours, maximum two tablets in 24 hours, every three weeks.  A subcutaneous injection of Aimovig 70 milligrams/milliliter (mg/ml) was given at this visit. Aimovig auto-injector 70 mg/ml, once per month for four months is prescribed.  The record indicates the injection of Aimovig greatly reduced the occurrence of the enrollees migraines. This enrollee has a diagnosis of intractable migraine with aura; without mention of status migrainosus. Prior treatment has been ineffective and the Aimovig injection was noted to have greatly reduced the occurrence of migraines. The medical literature indicates Aimovig is approved for the preventative treatment of migraine headaches. A study showed Erenumab (Aimovig) significantly reduced migraine frequency, reduced the impact of migraines on daily activities, and reduced the use of migraine medication over a period of six months. 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 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen.Findings:  Three physician reviewers found the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature concluded that patients with moderate-to-severe Crohns disease that was resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. However, there is limited evidence based recommendations to measure drug levels in patients being treated with ustekinumab. Specifically, target drug levels have not been established and there is a lack of data demonstrating improved health outcomes based on drug levels. Further, the American Gastroenterological Association (AGA) has stated that there is very low evidence to support measuring drug levels in patients failing therapy. For these reasons, the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the laboratory testing services of quantitation of therapeutic drug and immunoassay for analyte other than infectious agent antibody or infectious agent antigen was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF). Current medical literature is split on the efficacy of TIF. Sami Trad and colleagues found that TIF appears to be a valuable treatment alternative for the management of appropriately selected patients with moderate to severe chronic gastroesophageal reflux disease (GERD) symptoms, while Witteman and colleagues found that although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.  The American Society for Gastrointestinal Endoscopy (ASGE) College of Gastroenterology note that most studies involving TIF have been small with short-term follow-up and that prospective trials comparing these therapies with existing medical and surgical options by using objective measures of GERD as the primary endpoint could be useful in further defining the clinical role of these procedures. Given the uncertainty regarding its long-term efficacy, the requested TIF is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested TIF is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: 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 reviewers 1, 2, and 3 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: A 31-year-old female enrollee has requested authorization and coverage for brand name Strattera 80 mg. Findings:  The physician reviewer found that as noted in the medical literature, pharmacotherapy is considered first-line treatment for ADHD. In 2002, Strattera was approved for the treatment of ADHD from the U.S. Food and Drug Administration (FDA). Strattera is a non-stimulant selective norepinephrine reuptake inhibitor, which distinguishes itself from other standard pharmacologic interventions for ADHD. In 2017, the FDA approved generic versions of atomoxetine. In this case, the brand name Strattera has been well-tolerated and efficacious, appropriately dosed and approved by the FDA for the condition being treated. The therapy is safe, appropriate and consistent with good medical practice while ongoing treatment is reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the requested brand name Strattera 80 mg is medically necessary for treatment of this patients ADHD. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  This patient has cirrhosis of the liver based upon APRI score and thrombocytopenia.  Therefore, hepatitis C treatment is medically necessary to prevent further deterioration in his liver function and decompensation of his liver disease.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  In sum, the requested Viekira Pak is medically indicated for the treatment of this patient.