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

A 42-year-old female enrollee has requested Actiq for treatment of her migraine headaches.  Findings:  The physician reviewer found that literature yielded a study by Landy discussing the treatment of breakthrough migraine headaches with immediate release Fentanyl in the form of an oral transmucosal Fentanyl citrate (OTFC) (i.e., Actiq).The author concluded that transmucosal Fentanyl rapidly and effectively relieved acute, refractory migraine in outpatients and was associated with high patient satisfaction ratings. He adds that this medication was well tolerated by this group of patients that had already been treated with opioids in the past.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Enstilar foam, 0.005  0.064%, twice per day. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is being treated with Otezla. She was also treated with Enstilar, but there is no documentation of a treatment trial of other high potency topical steroids. The Health Plan has denied the request for coverage as not medically necessary because she has not failed the preferred agents. Given that calcipotriene and betamethasone are covered medications on the patients formulary and these are the components of Enstilar, it is reasonable that the patient first try the preferred agents prior to covering the branded medication. As there is no contraindication or documentation of treatment failure with the preferred agents, the medical necessity of the requested medication is not established. Therefore, Enstilar foam, 0.005  0.064%, twice per day 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: Overturned

The enrollee requested reimbursement for the SpaceOAR Hydrogel procedure. The enrollee has prostate cancer. He elected radiation therapy and a SpaceOar Hydrogel was placed prior to radiation therapy. This SpaceOAR Hydrogel is a biodegradable gel that is inserted between the prostate/rectum, by means of ultrasound guidance. The gel solidifies at body temperature, and then slowly degrades over several months. Its purpose is to shield the rectum from the radiation therapy which is directed at the prostate gland. At the current time, there are no similar products on the market that are approved by a governmental body. It has been shown to reduce the risk of rectal toxicity following external beam radiation, and it has no current competitors for this purpose. Scientific evidence in peer-reviewed literature supports a reduced rate of high-grade rectal complications with the use of SpaceOAR hydrogel; therefore, there is an improvement in health outcomes.Final Result: Two of the three reviewers determined that the requested services are not 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 urology 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: Overturned

The parent of a 22-year-old female, who has an eating disorder, has requested reimbursement for partial hospitalization program (PHP) services and on-going authorization and coverage for PHP services.Reviewer's Findings:The reviewing physician found that the patient had been in intensive outpatient treatment and this level of care was not sufficient. The letters written by her psychiatrist and her therapist assert a need for continued PHP treatment based on their evaluation and the documentation in the record. The intensity of her symptoms, including distorted body image, depressed mood and food restriction, puts her at substantial risk of relapse.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested surgery by an out-of-network provider for the treatment of her recurrent leiomyosarcoma. Findings:  The physician reviewer found that in the textbook Surgical Oncology:  Contemporary Principles and Practice, there is a chapter that addresses a strategy for treatment of patients with recurrent sarcoma.  There is clearly a precedent for the use of surgery in these patients. Based on this, there is supportive precedent for use of surgical debulking of recurrent sarcoma. However, there is no evidence that the patients surgery needed to be performed at a sarcoma treatment center, or that surgical intervention was necessary prior to December 2007. The submitted evidence does not establish that the surgical debulking was not within the scope of practice of an in-network oncologist/surgeon.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records document dense breasts.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed was likely to have been of greater benefit than other available methods of evaluation. Final Result: The reviewers determined that the service at issue was 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 reviewers are board certified in diagnostic radiology 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 Zepatier 50 mg/100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the 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 limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines do not require documentation of clinical risk factors to quality of treatment, recommending therapy in all patients regardless of factors such as alcohol use or intravenous drug use. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. In this case, documentation of negative NS5A resistance testing was submitted. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of her autoimmune thyroiditis and recurrent spontaneous abortion.  Findings:  Three physician reviewers found that a review of the relevant medical literature suggests that IVIG therapy is used to provide antibodies to patients who are susceptible to diseases for which there is no immunization available. The available scientific data do not support the utility and safety of IVIG for the treatment of recurrent pregnancy loss. The American College of Obstetricians and Gynecologists (ACOG) and the American Society of Reproductive Medicine (ASRM) concur that IVIG has not been thoroughly researched in clinical trials with positive results establishing it as a treatment option for this patients condition. In addition, the largest randomized controlled trial performed to date, reported no clinical benefit with IVIG therapy in this patient population. Consistent with these findings, the requested therapy remains investigational in this circumstance.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one level lumbar fusion surgery.Degenerative disc and facet joint disease of the lumbar spine is common in the aging population, and is one of the most frequent causes of disability. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity (Mobbs, R., et al.).In this case, the patient has advanced degenerative disc disease at L5-S1, mild neuroforaminal stenosis on the left at that level, and clinical and electromyography (EMG) evidence of moderate left L5 and S1 radiculopathy on the left and L5 radiculopathy on the right. The patients clinical and EMG findings corroborate magnetic resonance imaging (MRI) findings. Conservative treatment has been tried and failed, including over three months of medications, physical therapy, and an epidural steroid injection that was diagnostic. Under these circumstances, the requested one level lumbar fusion surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for private duty nursing in the home. This patients records demonstrate that she is stable, receiving feeding and routine catheter care. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines for SNF services, non-skilled person can reasonably provide this patients daily care. The patients daughter is providing adequate 24-hour custodial care. The providers note indicates there is no change in the patients condition and she does not have current skilled nursing needs. All told, the requested private duty nursing in the home is not supported as medically necessary for treatment of this patients medical condition. 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 with expertise in skilled nursing facilities 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 stereotactic body radiotherapy (SBRT) for treatment of his medical condition.  Findings:  Two physician reviewers found that standard therapies for early stage prostate cancer include prostatectomy, interstitial brachytherapy and IMRT. Proton therapy is also an option, though this treatment option has not been demonstrated to confer a substantial advantage over IMRT. This patient has high risk disease due to his substantially elevated PSA level. For high risk disease, the need for SBRT is not well-established in the literature. Most studies that included patients with high risk disease have enrolled small numbers of patients. In addition, the American Society of Radiation Oncology (ASTRO) model policy does not support the need for SBRT in high risk patients. All told, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested 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: The patient has requested reimbursement for 30 treatments of hyperbaric oxygen therapy in a hyperbaric oxygen therapy multi-chamber. In this case, the records did not document signs of ischemia, necrosis, or poor capillary refill that may indicate graft failure. While an edema of grafts was documented, this is not necessarily a sign of a failing graft and likely reflected normal postoperative appearance. There is a lack of consensus in current medical literature on the number of treatments to treat a failing graft, rather the number of treatments should be individualized based on response. In this clinical setting, hyperbaric oxygen therapy of any kind, whether monoplace or multi-place chamber, was not medically indicated. Therefore, 30 treatments of hyperbaric oxygen therapy in a hyperbaric oxygen therapy multi-chamber were not medically necessary for the treatment of this patientFinal 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 public health and general preventive medicine with sub-specialty certification in undersea and hyperbaric 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

A 52-year-old female enrollee has requested for Lyrica for treatment of her condition. Findings:  The physician reviewer found that the medical literature does not support the use of Lyrica for post-stroke pain. A systematic review of the literature on the pharmacologic treatment of central post-stroke pain showed that amitriptyline and lamotrigine are the only oral medications that have proven to be effective in the treatment of central post-stroke pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation at the tertiary level of care.Findings:  The physician reviewer found that This patient has confirmed type 2 hereditary angioedema. She has received appropriate treatment by a provider who specializes in diagnosing and treating this type of condition. Per the World Allergy Organization (WAO) in collaboration with the European Academy of Allergy and Clinical Immunology (EAACI), Early diagnosis and appropriate therapy are essential. It is important for this patient to continue to be treated by a specialist who is also able to manage her asthma with spirometry and other essential testing as needed. The available documentation supports an indication for a consultation at the tertiary level of care. Given these findings, the requested consultation at the tertiary level of care is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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

A 54-year-old male enrollee has requested septoplasty nasal surgery and reduction of nasal turbinate for treatment of his breathing difficulties. Findings:  The physician reviewer found that this patient does not meet medical necessity criteria for consideration of the proposed surgical intervention. There is no documentation of an attempt at medical management or the results of failure of medical management. This criteria is consistent with the recommended guidelines by the American Academy of Otolaryngology-Head and Neck Surgery Foundation for the management of patients with nasal obstruction and anatomic documentation of nasal septal deviation or spur formation. The results of the clinical studies show that outcomes for surgical intervention are significantly improved following failure of adequate medical management. In the absence of documentation indicating that the patient has undergone adequate attempts at medical management without success, the surgical treatment requested is not medically necessary and thus the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue was 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 diagnostic radiology 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: An enrollee has requested authorization and coverage for Epclusa with ribavirin for treatment of his hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This recommendation applies regardless of fibrosis stage.  The guidelines recommend that genotype 2 patients who have failed Sovaldi/ribavirin regimens should be treated with Sovaldi/Daklinza with or without ribavirin for 24 weeks. The guidelines also support re-treatment with Epclusa and ribavirin for 12 weeks. This is based on higher cure rates with use of Epclusa and ribavirin rather than Epclusa monotherapy.  Although hepatitis C treatment is needed, the requested medication regimen is not supported as medically necessary over the formulary medications, Sovaldi with Daklinza, for the re-treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication regimen 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 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.