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

An enrollee has requested authorization and coverage for prostatic arterial embolization. The American Urological Association (AUA) guidelines state that prostatic arterial embolization is not recommended for the treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH) outside the context of a clinical trial. The first-line therapy for management of BPH includes medical therapy with alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medications. For patients who fail to respond to medical therapy, a transurethral resection of prostate (TURP) procedure is indicated. In patients with large glands measuring 100 cc or more, Holep and simple prostatectomy are considered the standard of care. This patient is noted to have a prostate gland measuring over 100 cc. Moreover, randomized trials do not demonstrate improved efficacy of prostate artery embolization over TURP, Holep, or simple prostatectomy. All told, the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Findings:  Three physician reviewers found the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Final Result: The reviewers determined that the requested prostatic arterial embolization is not likely to be more beneficial for treatment of this patients medical condition than standard therapies.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 35-year-old female with a history of degenerative disc disease at L5-S1. A discogram performed in April 2005 showed diffuse contrast material throughout the disc at L5-S1 and posterior extravastion of contrast material. The patients provider believes the L5-S1 disc is responsible for the patients pain and is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure 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.Physician 2: The patient is a 35-year-old female with degenerative disc disease. She is seeking authorization for single disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers the Charite disc experimental.The current clinical evidence regarding the Charite disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 35-year-old female with degenerative disc disease. The patient has failed multiple conservative measures. Single level artificial disc replacement has been recommended by the patients provider. The Health Plan indicates there is insufficient peer-reviewed evidence demonstrating the efficacy of the proposed procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined that the requested procedure 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a GenVisc 850 injection series in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited.  In this case, the patient has tried and failed other conservative treatments, including corticosteroid injections, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a GenVisc 850 injection series in both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 21-year-old female with a history of recurrent dislocation of the left patellofemoral joint. She had continued pain following a repeat reconstruction of the medial patellofemoral ligament using an Achilles tendon allograft previously. The operative report documented grade three and four chondromalacia of the left patellofemoral joint. Later the patella was stable, although the records noted pain due to arthritis. The physical examination later revealed tenderness on both the medial and lateral aspects of the left knee and a trace effusion. She has failed treatment with physical therapy. The patient has requested coverage for Synvisc-One injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Synvisc-One injections are medically necessary for the treatment of the patients medical condition. Focal chondral defects due to recurrent patellar dislocations are common in the patellofemoral joint and can significantly impair quality of life. This patient has failed treatment with medications and physical therapy. Due to her young age, additional treatment is likely to be necessary in the future for a long-term solution. Medical literature indicates that viscosupplementation may result in a moderate degree of pain relief in patients with mild osteoarthritis. Intra-articular hyaluronic acid offers one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis pain and quality of life. Medical evidence supports the requested services in this clinical setting. Therefore, the requested Synvisc-One injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested serum infliximab tests (Prometheus Anser IFX tests) for evaluation of his Crohns disease.  Three physician reviewers found that in the management of this patient, therapy should be guided by response. Thus, if the patient is failing infliximab at 5 mg/kg every eight weeks then empiric escalation to 10 mg/kg is usually advised. Once at this threshold, continued symptoms would support switching to another agent. However, failure can be due to other causes which also need to be ruled out with a pouch exam including biopsies. Currently, there is a lack of an established role for serially following infliximab levels in this clinical setting to guide treatment decisions. Accordingly, the serum infliximab tests (Prometheus Anser IFX tests) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in 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: Overturned

The parent of a three-year-old female has requested occupational therapy for treatment of her autistic disorder. Findings:  The physician reviewer found that autism spectrum disorder is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. Often times, there are other concurrent diagnoses such as genetic conditions or mental health issues. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of several modalities including occupational therapy.Deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children. Individuals with autism spectrum disorder (ASD) have a range of occupational and performance problems that interfere with their full participation in daily activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficient language, behavioral problems, and sensory-processing difficulties (Case-Smith & Arbesman). This patient has deficits in balance, postural control/strength, bilateral coordination, endurance, fine motor strength and precision, upper limb coordination, locomotion, grasping, and object manipulation, preventing her from age appropriate acquisition of functional skills. With its focus on developing fine motor skills and self-help skills, developing age-appropriate functional independence, processing information, and regulating the response to incoming information, occupational therapy is well suited to affect positive change in children with ASD (Smith-Roley). Therefore, occupational therapy is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for for the medication, Belbuca 150 mcg (60 buccal films/30 day supply). The enrollee has chronic wrist pain. Electromyography resulted in a diagnosis of carpal tunnel syndrome. The enrollee was evaluated by an orthopedic physician. Records show the enrollee complains of constant bilateral wrist pain. The pain is described as burning, sharp, and shooting. The provider ordered Belbuca, every twelve hours, and hydrocodone-acetaminophen, 10mg/325mg as needed. Records show the enrollee also takes ibuprofen and meloxicam once a day. In this case, the question of whether this should be used for non-cancer modality seems reasonable. There is clear mention of the risks and benefits in the provider notes, and it appears that this is intended to be a short term trial. Therefore, it is reasonable to approve a one-month trial of this treatment.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male with moderate to poorly differentiated adenocarcinoma of the prostate, Gleason 4+3, and a PSA of 43. The results of a CT scan reveal two left iliac lymph nodes measuring 1.8c, and 1.9cm in size. The biopsy from the left side shows over 75% involvement. The patient is seeking authorization for intensity modulated radiation therapy (IMRT).Based upon Partins Tables, the patient has a 6% chance of the tumor being limited to the prostate and over a 40% chance of pelvic lymph node metastases. IMRT is a powerful tool in eradicating localized cancer; however, it is not the most appropriate tool for this patients advanced cancer. The patient should benefit most from a course of pelvic irradiation with boost of radiation to the prostate. IMRT is not medically indicated or necessary for treatment of this patients medical condition. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne test for evaluation of the enrollees left thigh pleomorphic sarcoma. Findings:  Two physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A male enrollee requested Pristiq ER 100mg for medical treatment of his major depressive disorder.  Findings:  The physician reviewer found that this patient has been diagnosed with major depressive disorder.  According to subjective report and validated rating scales, the patient was in remission and functioning well in all domains on the combination of bupropion and Pristiq.  He had previously tried alternative medications, including a recent trial of Effexor.  However, the other medicines were poorly tolerated.  Considering the patients history and the uniqueness of the disputed medication, additional pharmacologic trials are unnecessary.  The requested medication is well-tolerated and has been efficacious for this patient.  Continued treatment is reasonably expected to maintain the patients remission.  All told, Pristiq ER 100mg is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female has requested coverage for a past ChemoFx Assay provided for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the patient had been experiencing abdominal pain, and was found to have elevated tumor markers CA-125 and CEA. She underwent unilateral salpingo-oophorectomy and was found to have a stage I, grade 2, immature teratoma in the right ovary. There was no evidence of neoplastic disease elsewhere in the peritoneal cavity. The records indicate the patients tissue sample was sent for evaluation with the ChemoFx assay.  Use of chemotherapy sensitivity is not considered a standard of care, and is not routinely recommended. The National Comprehensive Cancer Network (NCCN) has designated use of this test as category 3, meaning that there is considerable disagreement that the intervention is appropriate. The American Society of Clinical Oncology (ASCO) also does not endorse the use of chemotherapy sensitivity testing in this clinical setting. In this case, NCCN guidelines would recommend adjuvant chemotherapy with 3 or 4 cycles of bleomycin/etoposide/platinum, for which good supporting evidence exists. There is no comparable evidence supporting the use a chemotherapy regimen determined by the ChemoFx assay.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old male enrollee requested autologous chondrocyte implantation (ACI) procedure for treatment of his right knee patellofemoral defect status post arthroscopy and debridement.  Findings:  Two physician reviewers found that although there are some clinical studies in favor of ACI of the knee, there are no long-term randomized controlled clinical trials demonstrating ACI to be superior to standard available alternatives. Specifically, studies have shown no difference between ACI and microfracture in the knee. Further, ACI is not likely to be more beneficial for treatment of this patients 8 mm chondral lesion with associated subchondral cyst of the patella than any standard treatment including microfracture.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Wegovy. The submitted documentation supports the medical necessity of the requested medication. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Currently, several pharmacologic therapies are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss. Therefore, Wegovy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injections. Findings: The physician reviewer found that medical evidence supports that Synvisc One injections are medically necessary. The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections. A review of current medical literature pertaining to viscosupplementation reveals mixed results. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Current research reports that intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit for patients with knee osteoarthritis, without major safety concerns. IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, there is evidence of benefit from prior injections. Moreover, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc One injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.