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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator into the airway.Findings:  Three of the three physician reviewers determined that implantation of a hypoglossal nerve stimulator is not likely to be more beneficial for treating of the patients medical condition than any available standard therapy. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult OSA to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant of or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection. Per the FDA, HNS is used to treat severe OSA for patients with an AHI of 20-65 who are at least 22 years of age, for whom CPAP has been tried and failed, and  who do not have a complete concentric collapse at the soft palate level. Records show that this patient has an AHI of 82.5 and has documented concentric collapse in the soft palate level area. Per FDA guidance, this patient is not a candidate for HNS. Therefore, HNS is not likely to be more beneficial for treatment of the patient's 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 reviewer 1 is board certified in internal medicine with subspecialty certification in  sleep medicine. Physician reviewer 2 is board certified in neurology with subspecialty certification in sleep medicine. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine. All three reviewers 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 Sovaldi and Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks (regardless of interferon eligibility). This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). The patient is not eligible for interferon-containing regimens due to rheumatoid arthritis, which can be exacerbated by interferon, and which is listed as a boxed warning on the prescribing information approved by the U.S. Food and Drug Administration (Ionescu, et al). The guidelines cite study data reporting that delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that the proposed treatment regimen of Harvoni for eight weeks is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score.  The fixed-dose combination ledipasvir-sofosbuvir (Harvoni) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. The treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. According to the literature, treatment duration of eight weeks can be considered in treatment-naive patients, without cirrhosis, who have a baseline HCV RNA level less than 6 million IU/mL based on post-hoc analysis of the clinical data from the ION-3 trial (Kowdley et al). Therefore, the patient should be approved for Harvoni to prevent further development and progression of fibrosis due to ongoing HCV infection and to avoid potential complications of advanced liver disease.  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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal decompression surgery at bilateral L2, L3, and L4. This patient presents with low to mid lumbar spine pain with radiation and numbness down both legs with MRI findings of degenerative changes of the lumbar spine with associated spinal canal stenosis, neural foraminal stenosis, and nerve root impingement. The records do not include documentation of symptoms of spinal stenosis such as neurogenic claudication or electromyographic evidence of radiculopathy. The patients lack of response to epidural steroid injections suggests that nerve root compression is not the likely the source of their pain. The patients mechanical pain in the lower back is worse than the leg pain, which does not follow a radicular pattern. Machado and colleagues reported that there is a paucity of evidence demonstrating the clinical efficacy of surgery for lumbar spinal stenosis, particularly when the diagnosis is not supported by clinical features, as in this patients case. Moreover, the requested decompression procedure could lead to iatrogenic instability and/or worsening of the patients symptoms. Given these findings, the requested spinal decompression surgery at bilateral L2, L3, and L4 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback. Neurofeedback is a type of biofeedback that teaches self-control of brain functions to patients by measuring their brain functions and providing feedback signals. Neurofeedback targets brain and cognitive functions through the use of electroencephalography (EEG) (Renton, et al). Neurofeedback has been studied in a variety of conditions including stroke, mild traumatic brain injury, epilepsy, autism spectrum disorders, and depression. However, per a review article on neurofeedback and its clinical applications, current research does not support conclusive results about its efficacy. Based on the documentation provided and current medical literature, the requested neurofeedback is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested neurofeedback 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 neurofeedback is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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

A 56-year-old male enrollee has requested an MRI of the lumbar spine for evaluation of his back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the lumbar spine in this patients case.  The peer-reviewed medical literature indicates that advanced imaging of the spine, such as MRI, should be reserved for select patient populations.  This includes patients with suspected infection, patients with suspected metastatic disease, patients with neurological deficits, and patients with a history of recent significant trauma.  For patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma, and no neurological deficits), it is medically appropriate to undergo a trial of conservative therapy, including non-steroidal anti-inflammatory medications (NSAIDs) and physical therapy, prior to advanced imaging, such as MRI.  This patient has back pain with no neurological deficits.  There is no documentation of conservative therapy, including NSAIDs and physical therapy.  There is no clinical concern of infection or metastatic disease, and there is no history of recent trauma.  All told, the requested MRI of the lumbar spine is not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the Stretta procedure. The enrollee has gastroesophageal reflux disease with esophagitis; partially controlled with proton pump inhibitors. He also has a hiatal hernia. An esophagogastroduodenoscopy revealed grade III esophagitis in the lower third of the esophagus and gastroesophageal junction, compatible with gastroesophageal reflux disease, and an irregular Z line in the gastroesophageal junction and erythema in the antrum; compatible with mild gastritis. His gastroenterologist is requesting a flexible, transoral esophagogastroduodenoscopy; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease (Stretta procedure). The physician believes this is a reasonable next step, as the enrollees gastroesophageal reflux disease is only partially controlled with medications. A professional society guideline on the role of endoscopy in the management of gastroesophageal reflux disease indicates the Stretta procedure received initial regulatory agency approval in 2000.  The Stretta procedure uses radiofrequency energy delivered to the distal esophagus, which can relieve gastroesophageal reflux disease symptoms for up to 10 years in the majority of individuals. Literature described more than 30 peer-reviewed studies which documented the safety and efficacy of the Stretta procedure.  Durable treatment outcomes, lasting at least 48 months, were documented in multiple studies.  The procedure is as an alternative to fundoplication in individuals with chronic heartburn. Since the enrollee has remained symptomatic on proton pump inhibitor therapy, he is a good candidate for the procedure.  The Stretta procedure is a safe and effective procedure for those with gastroesophageal reflux disease.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in internal medicine and gastroenterology 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

A 57-year-old female enrollee has requested medication Xenazine (tetrabenazine) for treatment of her tardive dyskinesia secondary to neuroleptic medication. Findings:  The physician reviewer found that Xenazine (tetrabenazine) was approved by the Food and Drug Administration in August 2008 to treat chorea associated with Huntingtons disease.  It has been considered as a treatment for other hyperkinetic movement disorders, such as Tourette syndrome, tardive dyskinesia, hemiballismus and dystonia.  However, at this time, its safety and efficacy for these disorders has not been established by well-designed clinical trials.  Thus, current medical evidence does not support the use of the requested medication in this clinical scenario. Due to a lack of evidence supporting its efficacy for the treatment of tardive dyskinesia, Xenazine (tetrabenazine) was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested authorization and coverage for consultation with a dermatologist and removal of two lesions for treatment of the enrollees squamous cell carcinoma, in situ, of the skin.  Findings:  The physician reviewer found that based on review of the available records, this patient was diagnosed with a squamous cell carcinoma in situ. The size of the lesion is not delineated in the medical records, but the pathology report indicates a size of 1.1 to 2.0 cm. Additionally, the pathology reveals involvement of the lateral margin, possibly making the lesion even larger. There are multiple options for treatment of this type of lesion, including excision, electrodessication and curettage, and topical immunotherapy with imiquimod (Love, et al; Reschly and Shenefelt). Given the location on the lower leg, healing can often be challenging and wide local excision might not be the best treatment for a lesion of this size. There is no documentation of a discussion of the risks and benefits of treatment options from the primary care physician, other than wide local excision. Lesions measuring greater than two centimeters, especially on the lower leg, are often indicators for micrographic surgery. This patient should be referred to a dermatologist for appropriate evaluation and discussion of treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested a wheelchair with a power recline feature for the treatment of his medical condition. Findings:  The physician reviewer found that the requested wheelchair with a power recline feature is medically necessary for this patient because he is at high-risk for development of pressure ulcers and has a history of such pressure ulcers. In addition, he cannot transfer independently and is unable to weight shift/position himself in his wheelchair due to his poor upper extremity muscle strength and poor trunk control. Furthermore, this patient uses a catheter and undergoes blood treatments and would benefit from the power recline feature which would allow him to increase the hip angle while in his wheelchair. All told, the patient meets Centers for Medicare & Medicaid Services (CMS) criteria for a power recline feature, and this device is a medically appropriate and necessary accessory to his power wheelchair.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old female who wishes to undergo a panniculectomy for treatment of excessive skin that developed following gastric bypass surgery in February 2002. It appears the patients weight has fluctuated since the gastric bypass procedure from a high of 306 pounds to a low of 213 pounds. The patient describes symptoms relative to her panniculus. The Health Plan has denied authorization for a panniculectomy on the basis that it is not medically necessary for treatment of the patients medical condition.The records submitted demonstrate the patient has not attained the weight loss anticipated with her gastric bypass procedure. Though the patient reports symptoms relative to her panniculus there is no physician documentation of these symptoms in the submitted records. The requested procedure poses a significant risk to the patient and should not be performed until the patient has attained the weight goal and diminished her comorbidities. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested laparoscopic gastric band (Lap-Band) removal and revision to sleeve gastrectomy for treatment of her complaints related to Lap-Band procedure.  Findings:  The physician reviewer found that there are published series of successful conversion of failed gastric banding procedures to other bariatric procedures including the sleeve gastrectomy and gastric bypass (Nguyen, et al). The records indicate that this patient underwent placement of a Lap-Band. She subsequently experienced severe esophageal stasis and dysphagia. The band was appropriately emptied, and the dysphagia and esophageal dilation/stasis resolved. The records indicate that she has failed to maintain adequate weight loss following placement of the Lap-Band despite attempts to appropriately adjust the band and a medical weight loss program. However, the patient does not have a current complication of the Lap-Band based on the documentation provided (Silecchia, et al). In addition, she does not meet the National Institutes of Health (NIH) Bariatric surgery criteria recommendations for revision surgery to the requested sleeve gastrectomy. All told, the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center (RTC) services for treatment of his medical condition.  Findings:  The physician reviewer found that although chemical dependency specialty services were indicated for this patient, the medical records do not demonstrate the medical necessity of the RTC level of care. Upon his presentation, the patient was not intoxicated and he was not in withdrawal. He was not psychiatrically distressed and his family was supportive of his recovery. The patient was motivated to re-capture sustained sobriety. The documentation from the facility included daily notes without a thorough psychiatric evaluation, mental status examination or treatment plan. There was no evidence in the record that the patient had engaged in chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, community sponsorship, intensive outpatient programming (IOP), or partial hospitalization programming (PHP). This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate at the time. Thus, RTC services were not medically necessary.   Final Result: The reviewer determined that the services at issue were 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 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

The mother for a five-year-old male has requested continued follow up care with an orthopedic surgeon specializing in oncology for treatment following surgery for Ewings sarcoma.  Findings:  The physician reviewer found that the care of this child can be broken down into two components; (1) treatment of his Ewings sarcoma and (2) his recovery from his limb-sparing surgery. As to the first, the treating oncologist is still in-Plan and will likely continue to treat the patient with chemotherapy as well as provide the majority of his long-term follow-up. As to the second consideration, the patient is recovering well from the limb-sparing surgery and it would be anticipated that the orthopedic surgeons involvement in the care of the patient will decrease. Any issues that might develop would be within the spectrum of care of other (pediatric) orthopedic surgeons, including those offered as in-Plan alternatives.