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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the DecisionDx-Melanoma Assay gene test for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay gene test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two out of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C. Findings: The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The patient is ineligible for the alternative for genotype 1a, Viekira Pak with ribavirin, due to pre-existing medical conditions, which can be exacerbated by ribavirin.  For these reasons, Harvoni is medically indicated 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for left eye cataract surgery with monofocal lens replacement. In this case, the patients visual acuity is noted as 20/25, with trace changes in the lens. However, testing results show mild reduction of contrast sensitivity in the left eye and reduced visual acuity on brightness acuity testing. Overall, these results support the notion that the cataract in the left eye is contributing to the patients visual symptoms. Given the results of the glare testing, while the patient should be aware that the glare from the right eye will still be present when driving at night even after cataract surgery in the left eye, the requested service is medically indicated to improve the patients symptoms. Therefore, left eye cataract surgery with monofocal lens replacement is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for Leukine therapy for treatment of his metastatic melanoma. Findings:  The physician reviewer found that this interest was provoked by the study by Spitler and colleagues. Their study involved 48 patients with completely resected stage III or IV melanoma who were given adjuvant granulocyte macrophage colony stimulating factor. These patients appeared to have superior disease-free and overall survival when compared to historic controls. The small number of patients as well as the fact that this was not a randomized study has cast doubt on the validity of this data. A randomized controlled trial was launched, but the data are not yet available. At the present time, there is a lack of data to indicate that there is clinical benefit to the adjuvant use of Leukine therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a Repatha SureClick 140 mg/mL pen injector. The patient has been diagnosed with borderline hyperlipidemia, type 1 diabetes mellitus, and polycystic ovarian syndrome. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol (LDL-C). In this case, the patient has some coronary risk but no documented coronary disease. The patients reported lipid levels are only modestly elevated, and there is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. The medical evidence does not support the requested medication in this clinical setting. Therefore, the requested Repatha SureClick 140 mg/mL pen injector 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 internal medicine with sub-specialty certification in cardiovascular disease 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 Forteo for treatment of her medical condition.  Findings:  The physician reviewer found that Forteo (teriparatide) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and nonvertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. These results are superior to other osteoporotic agents available.  Studies show that teriparatide was well tolerated with significantly greater increases in lumbar spine bone mineral density (BMD) from baseline compared with placebo, antiresorptive agents, or elcatonin/calcitonin. The sequence of therapy is important, especially in patients with severe bone loss. It has been demonstrated that the use of an antiresorptive agents such as bisphosphonate or denosumab prior to teriparatide decreases the beneficial metabolic effect of teriparatide on bone density. Alendronate reduces the ability of teriparatide to increase BMD and bone turnover in women. In postmenopausal osteoporotic women switching from teriparatide to denosumab, bone mineral density continued to increase, whereas switching from denosumab to teriparatide results in progressive or transient bone loss. These results should be considered when choosing the initial and subsequent management of postmenopausal osteoporotic patients. Given the above, teriparatide (Forteo) is medically necessary for this patient. It is best standard of care to prevent fractures and comorbidities by providing her the best therapy available. 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 endocrinology and metabolism 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 rituximab infusions. This patients records support a diagnosis of severe length dependent motor sensory axonal polyneuropathy. Prior treatment has included IVIG without substantial improvement and glucocorticoid, which was not tolerated. The provider reports that treatment with rituximab has resulted in symptomatic improvement for this patient. The use of monoclonal antibodies, such as rituximab, has been demonstrated to provide significant improvement in patients with neuropathic pain. Rituximab, a chimeric anti-CD20 monoclonal antibody, has shown benefit in the treatment of patients with peripheral neuropathy associated with immunoglobulin M (IgM) gammopathy. Moreover, current studies have reported a favorable side-effect profile. Therefore, the requested rituximab infusions are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested rituximab infusions are 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 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 reviewers 1, 2, and 3 are board certified in neurology 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

The patient is a 45-year-old female with idiopathic hypersomnia diagnosed in April 2002. There is documentation of severe pathological sleepiness with mean sleep latency of 4.3 minutes, otherwise normal sleep efficiency and normal sleep architecture with minimal snoring. The patient has been treated for three years with Provigil, with relief of symptoms. There have been no reported side effects to therapy. Her previous medication history included Ritalin 20mg, which was ineffective at clinically decreasing her daytime sleepiness. The patient changed carriers in October 2004, and her current Health Plan has denied authorization for Provigil on the basis that it is not medically necessary for treatment of the patients excessive sleepiness.The ICSD system lists four major categories of sleep disorders including dyssomnias. Dyssomnias are sleep disorders characterized by insomnia, excessive sleepiness or abnormal sleep-wake timing. Specific medicinal therapies are addressed for narcolepsy and obstructive sleep apnea. Idiopathic hypersomnia features excessive sleepiness without the other features sufficient to characterize narcolepsy. There is good documentation the patient has excessive sleepiness secondary to idiopathic hypersomnia (known as non-REM narcolepsy) based on a mean sleep latency test performed on 4/16/02.Provigil is effective in reducing excessive sleepiness. This has been characterized in many different conditions including obstructive sleep apnea nonresponsive to CPAP therapy, multiple sclerosis, and Parkinsons disease. Though Provigil is not FDA approved for idiopathic hypersomnia, there are multiple sleep conditions that feature excessive sleepiness that may be mitigated with Provigil. In fact, Provigil has been effective in controlling the patients excessive sleepiness for three years. Furthermore, it does not appear there is other alternative medicinal therapy available for this patient. Thus, continued use of Provigil is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a computed tomography (CT) scan. Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  In this patients case, he had a significant injury, resulting in multiple complex facial fractures.  While strictly speaking his fractures were not involving the base of the skull (as defined as the occipital, temporal, sphenoid, and ethmoid bones), the fractures that he did have were within a very short distance from the skull base.  In addition, he had ethmoid signs which could have been interpreted as a cerebrospinal leak.  These findings, in combination with the headache and sense of feeling slow, are reasonable indications for a CT scan of the brain.  All told, the CT scan performed was medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in diagnostic radiology 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 a knee scooter. Findings:  The physician reviewer found that Non-weightbearing restrictions are commonly employed for multiple weeks following hallux valgus repair to allow for proper healing with a stable alignment. Although non-weightbearing status can be challenging from a functional standpoint, but limitations can be mitigated by using various compensatory measures such as a walker. As noted in the medical literature, postoperative pain after hallux valgus repair can be addressed with various oral analgesics and local anesthetics. This patient underwent a left bunionectomy on 6/27/22. The patient reported pain and difficulty walking preoperatively and postoperatively. However, a specific functional history is not described in any significant detail in the available documentation. The records lack description of how the patient managed her mobility issues before surgery, or the patients plans for mobility after the surgery. There is no indication that the patient could not use a walker to safely manage her mobility-related activities of daily living. Moreover, the records do not adequately report that the patient has the ability to use a knee scooter. Furthermore, the providers notes do not include a recommendation for a knee scooter. All told, the requested knee scooter is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation 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 40-year-old female enrollee has requested bilateral breast magnetic resonance imaging for evaluation of her family history of breast cancer. Findings:  Three physician reviewers found that in the medical literature, a patient who has inherited a harmful mutation in BRCA1 or BRCA2 is believed to be about five times more likely to develop breast cancer than a patient without the mutation. Overall, studies have found high sensitivity for MRI, ranging from 71% to 100% versus 16% to 40% for mammography in these high-risk populations. The American College of Radiology (ACR) appropriateness criteria recognizes the increased sensitivity of MRI for high risk women and recommends MRI in this setting. Clearly, the increased sensitivity of MRI has been established in the screening of high risk patients. If mutation testing is not available, has been done and is non-informative, or if a patient chooses not to undergo testing, pedigree characteristics suggestive of high risk may be considered. This patient has personal history of ovarian cancer, family history of breast cancer, and extremely dense breasts. However, applying the definition of a high risk patient as suggested by the ACR, this patient does not meet these criteria, and therefore is not a candidate for MRI breast cancer screening. This is not only due to the lack of the BRCA gene, but the fact that this patient does not meet the criteria based on the other established models, not solely on the presence or absence of this gene. Thus, although MRI is an extremely sensitive diagnostic tool, if used to screen patients who are not at high risk, there would be a significant false positive, and it would lose its ability to be an effective screening exam. As such, its use would not likely provide any additional data relevant to this patients care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested mental health residential treatment center level of care for treatment of the enrollees generalized anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and Aspergers disorder.  Findings:  The physician reviewer found that although diagnosed with PTSD, depression, anxiety and autism, the patients symptom complex, behaviors and longitudinal history are also consistent with reactive attachment disorder. This may help explain her self-defeating coping strategies and emerging dysfunctional personality traits. Further, the patient has a poorly defined self-concept which complicates her process of identity formation and undermines her ability to effectively manage her emotions, impulsivity, and intrapsychic conflicts. In reviewing the clinical documentation, by the date indicated the patient had not yet consolidated the treatment gains needed to succeed in a less restrictive setting. Her treating providers continue to recommend residential care. On the subsequent date, the patient had suicidal ideation and attempted to depart the facility and run into traffic. Combining the current status, recent behaviors and clinical history, the patient will likely decompensate in the absence of the disputed treatment setting. Her behaviors will likely jeopardize her safety and possibly those whom she encounters in the community. All told, the evidence-based services provided thus far have been for active treatment and have been delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The services are reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the case in its entirety, and applying the current practice guidelines and relevant peer-reviewed literature, residential treatment services from the date indicated forward were and are safe, appropriate and consistent with good medical care and thus medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male who reportedly had rosacea and pre-cancerous skin lesions. Though a letter from the patients provider indicates the patient has rosacea and precancerous skin lesions there is no indication the patient underwent previous therapies for treatment of rosacea. The patient has been treated with liquid nitrogen for pre-cancerous lesions. He underwent laser therapy in July and August 2003 and has requested reimbursement for this therapy. There are many possible treatments for rosacea and actinic keratosis including topical medication, liquid nitrogen, and laser or light therapy. While use of laser therapy is an acceptable treatment for rosacea and actinic keratosis, the submitted evidence does not demonstrate the patient required such treatment. The provided laser therapy notes do not document clinical findings or reason for treatment. As such, there is insufficient evidence that the patient required the therapy at issue. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.