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

A 50-year-old male enrollee has requested repeat gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific evidence demonstrates that in the vast majority of cases, postoperative weight gain is due to noncompliance rather than mechanical failure. In the case of this patient, there is no documentation of gastrogastric fistula or other mechanical issues that would support revisional surgery. Although the endoscopy and upper gastrointestinal series are somewhat dated, the results were normal showing intact anastomosis and normal post-surgical changes. In the absence of recent workup demonstrating mechanical failure of the original procedure, the medical necessity of repeat gastric bypass is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee has requested for a magnetoencephalography (MEG) for evaluation of his intractable epilepsy.  Findings:  Three physician reviewers found that MEG scans have been shown to be helpful in localizing an epileptic focus and aid in placement of a cortical grid or depth electrodes in preparation for epilepsy surgery. This patient is clearly a candidate for epilepsy surgery. MEG is widely used at comprehensive epilepsy surgery centers prior to epilepsy surgery and is appropriate for this patients pre-surgical workup.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy surgery. Indications for a tonsillectomy include recurrent throat infection with documentation. Clinicians may recommend a tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year; at least five episodes per year for two years; or at least three episodes per year for three years. There should be documentation in the medical records for each episode of sore throat, and documentation of one or more of the following: temperature greater than 38.3 degrees Celsius, cervical adenopathy, tonsillar exudates, or a positive test for Group A Beta-Hemolytic Streptococcal infections (GABHS). While recurrent infection remains the most common indication for an adult tonsillectomy, there is a growing rate of tonsillectomies performed for upper airway obstruction. In the adult population, a tonsillectomy is the appropriate first line treatment in select patients. Tonsillectomy has been shown to be a very effective treatment regardless of the severity of the obstructive sleep apnea (OSA). In this case, the patient had three episodes of strep throat infection this year and did not undergo a sleep study to document OSA. Although she has enlarged tonsils, she does not meet the criteria for a tonsillectomy for either recurrent infection, or for OSA. Accordingly, the requested tonsillectomy surgery is not medically necessary for this patient.Final Result: The reviewer determined that the requested procedure 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 otolaryngology, with subspecialty certification in plastic surgery within the head and neck, 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 an oral appliance for treatment of his obstructive sleep apnea.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested device in this patients case.  An oral appliance is an appropriate therapy for patients with mild obstructive sleep apnea.  There is sufficient support for an oral appliance in this clinical setting.  The requested device is an appropriate treatment for this patient.  All told, the requested oral appliance is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 pulmonary disease and 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: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam radiation therapy (PBRT). This patients treating provider has supplied the results of a PBRT versus photon beam radiation therapy plan comparison, which shows that the photon-based IMRT plan results in excessive exposure to the patients contralateral salivary tissues and oral cavity. If delivered, the photon based plan would lead to an unacceptable risk for xerostomia and dysphagia. The PBRT plan is able to significantly reduce the exposure to the contralateral salivary tissues and oral cavity, thereby minimizing the risk for chronic radiation-induced toxicity. In addition, the requested PBRT for this patient is supported by the American Society of Radiation Oncology (ASTRO), which recommends coverage for unresectable head and neck malignancies and for patients who cannot be treated safely with photon-based treatment techniques. The records provided for review document that this patients disease could not be resected to negative margins. Furthermore, there are numerous high quality prospective clinical outcomes published in the peer-reviewed medical literature demonstrating the safety and efficacy of PBRT for management of head and neck malignancies. Given this support, the requested PBRT is medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested coverage for Orthovisc injections for treatment of the his anterolateral ankle pain after an inversion injury.  Findings:  Three physician reviewers found that the patient suffers from ongoing foot and ankle pain. He had a talonavicular fusion which is noted to have progressed to nonunion. The patients provider has recommended Orthovisc injections for ankle osteoarthritis (OA) as demonstrated on magnetic resonance imaging (MRI). The records indicate that he has also undergone a course of physical therapy and anti-inflammatory drugs. The peer reviewed medical literature including case series and clinical trials does not currently support the long-term safety and effectiveness of viscosupplementation for ankle OA. As concluded by Pleimann and colleagues, Anecdotal use in OA of the ankle has been encouraging, but larger scale, controlled studies need to be performed. In addition, long-term investigations will better define the duration of effectiveness that viscosupplementation provides. For these reasons, the requested therapy is not likely to be more beneficial than standard therapies for treatment of this patients ankle OA.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested an ultrasound for carotid intimal thickness (0126T) for evaluation of her high cholesterol. Findings:  Three physician reviewers found that carotid intimal medial thickness is a valid surrogate for the presence of coronary artery plaque in individuals at an intermediate 10 year risk for death or myocardial infarction (MI). In the November 2010 updated Task Force Guidelines for the assessment of cardiovascular risk in asymptomatic adults, the American College of Cardiology Foundation/American Heart Association Task Force indicated that carotid intimal medial ultrasonography is useful for patients at intermediate risk. This patient has low risk by the National Heart, Lung and Blood Institute (NHLBI) calculator and is not considered to be at an intermediate risk. Therefore, the disputed procedure was not likely to be more useful for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene testing for evaluation of his medical condition.  Findings: The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma gene test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma gene test was likely to have been superior over other methods of evaluating this patient.  Final Result: Three 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:  All three Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The parent of an eight-year-old male enrollee has requested  for speech and language therapy for treatment of the enrollees pervasive developmental disorder. Findings:  Two physician reviewers found that the patients last speech evaluation was over 3 12 years ago. Currently, there is a lack of justification for medical necessity for speech and language therapy. A current comprehensive speech and language evaluation should be performed to provide necessary data to decide on the potential efficacy of therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested authorization and coverage for the magnetic esophageal sphincter augmentation (LINX procedure) for treatment of the enrollees gastroesophageal reflux disease (GERD) with severe atypical chest pain. Findings:  The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, Jobe and colleagues noted that it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. This patient has GERD as based on pH recording that has not benefited to a significant degree from acid suppression treatment. Anti-reflux surgery with LINX is appropriate in the patients case and can be expected to be more beneficial than standard therapy. Final Result: All three reviewers determined that the requested procedure is likely to be more beneficial for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: The patient has requested reimbursement and prospective authorization and coverage for brand name Ventolin HFA Aerosol Solution. The U.S. Food and Drug Administration (FDA) has approved Ventolin HFA for the treatment of patients with asthma. Moreover, the Global Initiative for Asthma (GINA) reported on the safety and efficacy of Ventolin HFA as demonstrated in the medical literature. Based on the available records, this patient has tried and failed at least one generic alterative to brand name Ventolin HFA Aerosol Solution. The provider charted that the patient has responded well to treatment with brand name Ventolin HFA. Therefore, the brand name Ventolin HFA Aerosol Solution was and is medically necessary for treatment of this patient.Final Result: The reviewer determined that the medication at issue was and 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 subspecialty certifications in pulmonary disease and critical care 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 is a 76-year-old man who was diagnosed with prostate cancer. His PSA was 7.0 in April 2005 and biopsies in June 2005 revealed a high volume of tumor. The left base had a Gleason score of 4+5 with 13% involvement, right apex had a Gleason score of 4+4 with 44% involvement, right mid had a Gleason score of 4+5 with 100% involvement and right base had a Gleason score of 4+5 with 100% involvement.  Physical exam described a firm nodule in the right gland. Ultrasound revealed tumor extension through the gland and seminal vesicle involvement bilaterally. The patient was started on hormone therapy in July 2005. The patient requests treatment with external beam radiation therapy (EBRT) with gold seed implantation followed by high-dose-rate brachytherapy (HDR-B). The Health Plan has denied authorization and coverage based upon their determination that the requested therapies are not medically necessary.This patient has advanced disease and a very high-grade tumor. His PSA is 7.0, Gleason score 9 and he is stage T3b Nx Mo.  The Partins Tables suggest an incidence of pelvic lymph node involvement as high as 29%. Hormone therapy (started in July 2005) is the most effective treatment at this time and both sides agree with that approach, but unfortunately, the tumor does not always respond. To determine the best course of treatment for the patient, the PSA should be rechecked and a digital rectal examination (DRE) should be performed.  If the patient has had a good response to hormone therapy and DRE shows no palpable tumor, HDR-B is not medically necessary. If however, there is still significant tumor volume, HDR-B is medically necessary and should be authorized.  EBRT with gold seed implantation is not medically necessary regardless of the clinical response to hormone therapy.  With a good response to hormone therapy, EBRT is not required.  If there has not been a good response to hormone therapy and HDR-B is required, the role of EBRT is no longer significant and HDB-R is the conformal therapy of choice.  Based upon the information set forth above, I have determined that EBRT with gold seed implantation is not medically necessary for treatment of the patients medical condition. In addition, I have determined that HDR-B is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. If the results of a PSA recheck and DRE reveal significant tumor volume, HDR-B should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the requested medication, Otezla, 30mg for moderate to severe psoriasis involving a total body surface area of greater than 10 percent. The record indicates lesions on her scalp, back, arms and legs. She had been treated with the topical agents, Taclonex and Clobetasol, but her condition was only partially alleviated. A trial starter pack of Otezla was provided to the enrollee and her psoriasis had completely cleared with Otezla. The enrollee was continued on Otezla, along with Fluocinonide. On a subsequent visit, mild, scaly psoriasis on the scalp and trunk are noted. At the next visit, the record indicates the enrollees psoriasis is now moderate in severity, and also developed along her scalp. The plan was for Enstilar topical foam and Otezla. Her provider indicates she has tried and failed high dose steroids. The enrollee has a history of moderately severe psoriasis. The plaques are on her arms, trunk and scalp and are symptomatic. She has tried and failed topical medications, such as steroids and Enstilar/Calcipotriene. Otezla was first prescribed several years ago and the enrollees psoriasis cleared with this medication. Although there are periods of remissions and flares, the Otezla has been most effective in relieving and improving her psoriasis. Stopping the Otezla now, after the extended length of time she has been on it, may potentially result in a disease flare up.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old male enrollee has requested Y-90 Sirtex Spheres for treatment of his primary liver cancer.  Findings:  The physician reviewer found that fror this patient who has unresectable HCC, radioembolization may be effective at controlling his liver tumors. Failure of chemoembolization does not suggest that radioembolization will be ineffective, as the mechanism of action of radiation and chemotherapy are different. The bulky liver lesions are likely to continue and increasingly impact quality of life in the immediate future given the progression in size.  While systemic therapy with sorafenib remains the standard approach, systemic therapy, results in limited efficacy in controlling bulky tumors. Thus, a combined approach of sorafenib in conjunction with radioembolization is a medically reasonable therapeutic plan. As radioembolization is an established, accepted treatment modality, its use is medically necessary for treatment of this patient with bulky liver tumors.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for eculizumab therapy for treatment of the enrollees C3 glomerulonephritis. Findings:  The 3 physician reviewers found that Eculizumab has not been U.S. Food and Drug Administration (FDA) approved for use in the treatment of C3 glomerulonephritis. This monoclonal antibody has been FDA approved for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. However, there are clinical trials that are ongoing currently determining the efficacy of eculizumab in C3 glomerulonephritis. Both atypical hemolytic uremic syndrome and C3 glomerulonephritis are disorders of alternate complement pathway resulting in abnormal production of membrane attack complex (MAC), leading to damage to various organs including kidneys. The goal of this therapy is to block the production of membrane attack complex, thus preventing the cascade of events leading to endothelial injury in various organs. The medical evidence supports the requested medication in this clinical setting, as eculizumab has been used with success in patients with C3 glomerulonephritis, preventing further renal injury.  In this patients case, off-label usage of eculizumab is warranted to see if her renal function reverses. Steroids, plasma exchange and other immunosuppressive agents have not been found to be useful as definitive agents for this condition. Dialysis is only a supportive treatment for renal failure. Based on the current evidence, eculizumab therapy is likely to be of greater benefit than other treatment options in this patients case. Final Result: The 3 reviewers determined that the medication 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 reviewer number one is board certified in pediatrics with sub-specialty certification in pediatric nephrology 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric nephrology 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric nephrology 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.