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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing (CPT codes 81200, 81209, 81240, 81241, 81242, 81251, 81255, 81257, 81260, 81290 and 81330). Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this patients case. Genetic testing technology has evolved rapidly over the past decade, and it is now possible to screen for a large number of conditions simultaneously. This testing strategy is known as expanded carrier screening. Per the medical evidence, expanded carrier screening is an acceptable strategies for prenatal carrier screening. Therefore, gene panel testing (CPT codes 81200, 81209, 81240, 81241, 81242, 81251, 81255, 81257, 81260, 81290 and 81330) was likely to have been of greater benefit 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genetics and is 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 breast reduction surgery for treatment of her hypertrophy of breasts.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has the classic symptoms for macromastia. Symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition.  Nonoperative treatments are unlikely to improve her pain.  Per the medical literature, breast reduction has been demonstrated to be curative for symptomatic macromastia, and peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy.  All told, the requested breast reduction surgery is medically indicated 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 plastic 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: The patient has requested authorization and coverage for Euflexxa injections in both knees. Findings: 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 has a history of relief from prior injections received. Given the patients limited options, with the alternative being a total knee arthroplasty, and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in both knees 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hypoglossal nerve stimulator.Findings:  Two of the three physician reviewers found that there is sufficient support for the requested device in this clinical setting. The records document obstructive sleep apnea. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. The provider has reported that the patient is not an appropriate candidate for oral appliance therapy. The medical evidence supports the requested device in this patients case. Therefore, the requested hypoglossal nerve stimulator is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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: Upheld

Nature of Statutory Criteria/Case Summary: A 31-year-old female enrollee has requested authorization and coverage for Port-A-Cath placement. Findings : The physician reviewer found that the medical literature does not support the medical necessity for the requested services in this patients case. The treatment plan indicated therapy with IVIG. However, there is no documentation of failed peripheral intravenous placement. Moreover, the record provided does not show that this patient is going to require treatment with IVIG long-term or that she has inadequate peripheral venous access. Additionally, the medical literature does not support that IVIG is caustic to the veins requiring central line placement in the form of a Port-a-Cath. As such, Port-A-Cath placement is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 internal 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

The parent of a 17-year-old male has requested laser hair removal for treatment of his recurring pilonidal cyst.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  Pilonidal disease can be extensive, and recurrences are common.  This condition arises from an inflammatory response in the hair follicles near the gluteal cleft.  Wide excision is often performed, and healing times are often quite slow.  The use of postoperative laser hair removal has been shown to be effective to help prevent recurrences.  This patient underwent an extensive excision for local control of the disease.  Laser hair removal was recommended to prevent recurrence, and he subsequently developed recurrent disease.  There is a growing body of supportive data for laser hair removal for this condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Humira for treatment of the patients plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The patient has a history of psoriasis and psoriatic arthritis and has requested coverage for Humira. However, the patient is currently being treated with Otezla. There is a lack of support to prove that the efficacy of the combination of Otezla and Humira is greater than the effect of either alone. Additionally, the current evidence has not demonstrated the safety of this combination of agents. There are other U.S. Food and Drug Administration (FDA) approved single agents that may have better efficacy than the specifically excluded combination of Humira and Otezla. Therefore, Humira is not medically necessary for the 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 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 partial-breast irradiation for treatment of her medical condition.  Findings: Two physician reviewers found that APBI delivers adjuvant radiation to part of the breast after breast conserving surgery for early stage breast cancer. APBI is controversial, and is not considered standard therapy outside of a clinical trial. APBI is an emerging standard of care for women with low risk of recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state compared to standard whole breast radiation, several recent studies document an inferior cosmetic outcome with APBI. Follow-up is limited and studies are ongoing. In addition, the American Brachytherapy Society does not recommend APBI for women younger than 50. Currently there is a clinical trial studying whole breast radiation therapy compared to partial breast radiation therapy in treating women who have undergone surgery for ductal carcinoma in situ or stage I or stage II breast cancer (NSABP B-39/RTOG 0413 trial). In sum, long-term follow up is needed to ascertain if there is any risk or benefit in the use of APBI with respect to late toxicity and long-term tumor control. Given the controversy surrounding its use, and the fact that whole breast radiation is a safe, and effective standard therapy, APBI would not be considered likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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 reviewers are board certified in radiation oncology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate. Findings:  The physician reviewer found that based on current medical literature and in consideration of the presented clinical records, morphine sulfate is not medically necessary for treatment of the patients medical condition. The requested medication is excessive in light of the patients condition and in addition to the medication regimen. The medical records have shown the patient to have chronic nonmalignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study , there are well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by another study, which states that, Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic lower back pain. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic pain Furthermore, these therapies work best in a multidisciplinary rehabilitation context. There are a variety of anticonvulsants and antidepressants that are considered adjunctive to pain management therapy. If there is poor response to conservative therapy then surgery should be considered. Recent studies have shown that high dose opioids are associated with a high risk of dependence and tolerance. Long term opiates are more likely to cause adverse outcomes including adrenal suppression and dependence. Based on current medical literature and in consideration of the presented clinical records, morphine sulfate is not medically necessary for treatment of this patients medical condition. 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 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: Upheld

The patient has requested authorization and coverage for Vyvanse. There is evidence-based literature to support the use of Vyvanse for the treatment of attention deficit hyperactivity disorder and binge eating disorder. This patients diagnoses include chronic fatigue syndrome, systemic lupus erythematosus and Sjogrens syndrome. There is a lack of peer-reviewed, evidence-based literature or guidelines to support the use of Vyvanse for the treatment of chronic fatigue associated with autoimmune disease. Therefore, the requested Vyvanse 20 mg 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 internal medicine with subspecialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulance. Findings: In a randomized phase III clinical trial, a study reports that plecanatide (brand name Trulance) significantly improved constipation and its related symptoms with a low rate of adverse events. The American College of Gastroenterology (ACG) guidelines on the management of irritable bowel syndrome note that three studies evaluating for safety and efficacy concluded that plecanatide appeared effective for relieving overall and individual symptoms of irritable bowel syndrome, constipation-predominant. In this case, given that the patient has a diagnosis of irritable bowel syndrome with constipation and has failed multiple stimulant laxatives, osmotic laxatives, and fiber, the requested medication is medically indicated.  Therefore, Trulance 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 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 50-year-old postmenopausal woman who was diagnosed with osteoporosis of the lumbar spine and osteopenia of the hips following a DEXA scan seven months ago. The etiology of the low bone density is unknown. She has no documented fragility fractures and no apparent risk factors beyond her T scores.  Based upon the extension study of a recent study of combination therapy in postmenopausal women, the patients provider wishes to begin a two-year course of Forteo (parathyroid hormone) followed by bisphosphonate. The Health Plan has denied the request for Forteo based upon their determination that treatment with Forteo is not medically necessary absent an intolerance or failure of a bisphosphonate agent.The current standard is to treat with parathyroid hormone either in combination with or before a bisphosphonate regimen for those women who have failed other treatments or have very severe osteoporosis.  Failure in the treatment of osteoporosis is defined as statistically/clinically significant decreases in bone mineral density or the occurrence or recurrence of fragility fractures while on treatment, or an intolerance to the first line treatment regimen.  Very severe osteoporosis is typically defined as T-scores greater than -4.0 standard deviations below the mean for young adult women or a combination of other risk factors such as old age, a family history of hip fractures, smoking or a high risk of fracture as assessed by standard risk indices.  This patient has not failed a bisphosphonate treatment regimen, nor does she meet the generally accepted definitions of severe osteoporosis.   The patients provider cited an extension study by Black, et al. that showed women who were treated with bisphosphonates after either a combination regimen of parathyroid hormone and bisphosphonate or parathyroid hormone alone had better outcomes with regard to the maintenance of bone mineral density gains achieved in the initial study. This study contained no clinical fracture data. Based on the scientific evidence currently available, the use of Forteo in this patient is not medically warranted.For the reasons set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-month-old male enrollee has requested hospital stay for treatment of the enrollees pneumonia.  Findings:  The physician reviewer found that the hospital stay provided during the specified timeframe was medically necessary for treatment of the patients medical condition. The patient was presented to the ER after a seizure associated with fever. At the time of inpatient admission the patient was reported to have hyponatremia with ketones in the urine. The physician notes also noted that the patient had pneumonia at the time of admission. The patient was treated with IV fluids as well as IV and oral antibiotics. Although the patient was not seizing and fever had come down by the time of admission, concerns regarding pneumonia and treatment of hyponatremia still existed. Thus, the inpatient treatment prescribed by the admitting physician in this case was reasonable and medically necessary. Furthermore, the medical literature cited above provides evidence that caution should be exercised in children with hyponatremia. Therefore, the services at issue were medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested a full body positron emission tomography (PET) scan for evaluation of his pancreatic cancer.  Findings:  Three physician reviewers found this patient has known pancreatic carcinoma and mesenteric encasement. There is no report of a prior PET for staging. He has undergone chemotherapy and is being considered for resection. The records indicate the PET has been requested to evaluate the patient for distant metastases. The National Comprehensive Cancer Network (NCCN) guidelines acknowledge there is evidence PET with CT attenuation is valuable in the evaluation for distant metastases. For these reasons, the requested PET would be more valuable for this patient at this juncture than any other test available.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested the growth hormone (GH) therapy with Genotropin for treatment of the enrollees small for gestational age (SGA).  Findings:  The physician reviewer found that the patient has a history of SGA and has extreme short stature with failure to catch up in growth by two to three years of age after resolution of critical illness. She has reportedly gained appropriate weight with total parenteral nutrition, yet has a persistently poor growth velocity. Thus, she meets the U.S. Food and Drug Administration (FDA) criteria for a trial of GH therapy. According to the American Association of Clinical Endocrinologists and the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children who have been SGA is considered an indication for GH treatment in children. Treatment with GH in children with SGA usually stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. GH treatment regimens prescribed for children with SGA have a reassuring safety profile (Ranke and Lindberg). All told, the requested GH therapy with Genotropin has been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 17-year-old male enrollee have requested a bilateral reduction mammoplasty for the treatment of gynecomastia.  Findings:  The physician reviewer found that there is no evidence of rashes, nipple drainage or obvious masses. The record reveals no evidence of functional impairment due to this condition.