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

The patient has requested authorization and coverage for endoscopic foraminal decompression of spinal cord at left L4-5. Researchers concluded that endoscopic foraminotomies allow for effective foraminal decompression, though clinical studies are necessary to further evaluate complications and efficacy. In this patients case, there is evidence of spinal instability at L4-5 as well as presence of a synovial cyst, which is another sign of spinal instability. Given the presence of spinal instability, further decompression would likely exacerbate the patients lumbar radiculopathy. The efficacy of endoscopic foraminotomy in addressing the patients spinal instability is not supported in the medical literature. All told, the requested endoscopic foraminal decompression of spinal cord at left L4-5 is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Tomosynthesis has been approved by the U.S. Food and Drug Administration (FDA) for clinical use. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the diagnostic procedure 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. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested Restylane (hyaluronic acid) injections for treatment of her CREST syndrome. Findings:  The physician reviewer found that the patient does not appear to be on any systemic therapy for other symptoms of CREST syndrome, such as motility agents for the gastrointestinal tract or calcium channel blockers for Raynauds syndrome.  There is currently no medical literature examining the effectiveness of hyaluronic acid fillers in the treatment of scleroderma.  There are reports of the use of hyaluronic acid fillers to improve the appearance of linear scleroderma as noted by Beylot, but this would be considered a cosmetic treatment. There is a lack of medical literature supporting the use of hyaluronic acid fillers in this case.  Additionally, the patient does not appear to have tried and failed any of the standard therapies, including methotrexate, mycophenolate mofetil or cyclophosphamide. Given the lack of literature showing efficacy, and because the patient has not tried and failed standard therapies, Restylane injections are not clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 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 recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present, rather than 99% when resistance is absent. Given that NS5A was positive for resistance to Zepatier and Viekira XR, Zepatier monotherapy for 12 weeks is not recommended in this case. For these reasons, although treatment is needed regardless of fibrosis stage, the request Zepatier for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female with a multiplicity of complaints. She has been receiving human growth hormone treatment for an unknown duration of time with an equivocal response. The patient has a history of chronic fatigue, sleep disturbances, panic attacks, pain, and decreased cervical range of motion. Laboratory studies revealed an IGF-1 level of 77. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating growth hormone therapy is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records reveals no conclusive evidence of growth hormone deficiency or any pituitary dysfunction for that matter. The patient has refused definitive growth hormone testing. Her symptoms are nonspecific and her IGF-1 is not diagnostic of adult growth hormone deficiency. As such, there is no clinical indication for continuation of growth hormone therapy in this case. Accordingly, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male has requested bronchial thermoplasty for treatment of severe persistent asthma.  Findings:  Three physician reviewers found that the patient is a former smoker, with a history of poorly controlled, severe, persistent asthma, fibromyalgia, hypercholesterolemia, depression, gastroesophageal reflux disease, sinus disease, and atopy. Bronchial thermoplasty, the third of a planned three treatments, has been requested by the patient and the patients provider to treat the patients asthma. The patient has undergone the thermoplasty procedure on two previous occasions. A third planned treatment is requested for the upper lobes. The patient is currently receiving inhaled bronchodilators, inhaled corticosteroids, as well as inhaled and oral corticosteroids for severe persistent asthma. The patient continues with symptoms of shortness of breath, chest tightness, and exertional dyspnea despite these therapies. The patient has had significant radiation and chemical exposures that were work related. Pulmonary function tests done were normal, including forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity for carbon monoxide (DLCO). A cardiopulmonary exercise test was also normal. A computed tomography (CT) scan of the chest was normal. An allergy evaluation  was negative except for Bermuda grass. After the patients hospitalization a year ago, the patient was on oral prednisone with tapers. The most recent office note, written four months ago, indicates the patient is on an alternating dose of 20 and 10 mg per day. He continues to have significant symptoms with exacerbations despite the bronchial thermoplasty interventions (Pavord, et al). Bronchial thermoplasty is a non-drug procedure that was approved by the FDA for treatment of severe and persistent asthma in 2010. The procedure delivers thermal energy to the airways to reduce airway constriction in asthma patients. It is performed as part of a bronchoscopy. It has been shown to improve air flow and reduce exacerbations, emergency room visits, hospitalizations, and lost days at work in patients with moderate and severe, persistent asthma. These benefits can persist up to two years after the initial procedure. Consistent with these findings, the requested procedure is likely to provide this patient with greater benefits than standard interventions for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for eight weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the recent 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 hematology 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

A 60-year-old male has requested approval for brachytherapy services for treatment of his adenocarcinoma of the prostate.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of brachytherapy in this patients case.  There are several single institution and multi-institution studies which support using high-dose rate or low-dose rate brachytherapy as monotherapy, in which intermediate-risk patients are included in the cohort or represent the entire study cohort.  Brachytherapy is an established treatment for prostate cancer.  For the indication of intermediate-risk prostate cancer, brachytherapy as monotherapy is not an advisable treatment for all patients, although select patients with disease confined to the prostate and other favorable features could be considered appropriate candidates.  The current medical evidence supports the requested services in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old male enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment center (RTC) services were not medically necessary for treatment of the patients medical condition. On admission the patient denied suicidal ideation and the psychiatric progress notes report that the patient stated that he was too scared to attempt suicide. His drinking was binging in nature and not daily, and he had maintained abstinence for days prior to admission. There was no indication that his psychiatric symptoms would interfere with his maintaining abstinence or with recovery outside of a 24-hour structured setting, or would represent a deterioration from his usual status, or posed risk of serious harm to self or others that could not be managed outside of a 24-hour structured setting. In addition, he had no medical symptoms that would interfere with his maintaining abstinence and recovery outside of a 24-hour structured setting. He had major functional impairment in work/school in that he had stopped attending classes, however he was independent in his activities of daily living (ADLs), lived at home with his family, and his physical health was intact. Given all of the above, his condition did not meet the medical necessity criteria for residential level of care and he could have safely been treated at an outpatient level of care along with community based resources such as 12-step programs. Based on the medical literature cited above and the documentation submitted for review,  RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services. Findings:  The physician reviewer found that applying the child and adolescent level of care utilization system (CALOCUS) to determine the necessary level of care for children, this patients records do not support the medical necessity of the services provided. The patient presented a composite score of 18 which correlates with intensive outpatient services. Overall, the progress notes do not document a serious mental health symptoms on the part of the patient. There was no documentation of serious depression, anxiety or psychosis. During her stay, the patient was noted to be cooperative in treatment and was noted to be benefiting from her therapies as judged by her improved insight and judgment. For these reasons, the services at issue were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing (unlisted molecular pathology) for evaluation of the enrollee, who had an elevated prostate-specific antigen (PSA) level. Findings:  The 3 physician reviewers found that the Confirm MDx testing is a multiplex polymerase chain reaction (PCR) assay measuring DNA methylation of three biomarkers associated with prostate cancer: GSTP1 APC and RASSF1. Two recent studies have suggested that Confirm MDx can accurately predict the need for repeat biopsy in a patient with negative biopsy results. However, these studies are recently published and need continued validation from widespread clinical use. The clinical utility awaits evaluation by a prospective, randomized clinical trial which is currently recruiting (PASCUAL study). While Confirm MDx may eventually have a role in treatment decision making for patients with prostate cancer risk, there is limited data on clinical outcomes to currently support routine use.  At this time, the superior efficacy of gene testing (unlisted molecular pathology) provided has not been established. Final Result: The 3 reviewers determined that the services at issue were 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 urology 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 urology 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 urology 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 patients parent has requested authorization and coverage for one to two hours per week of speech therapy services. The records indicate that this patients autism spectrum disorder (ASD) has substantial behavioral roadblocks including inattention and restrictive behaviors, which have prevented his successful participation in speech and language therapy. Syndromes such as Smith-Magenis can be characterized by oppositional and aggressive behaviors that may prove challenging for conventional approaches to speech and language therapy. However, introduction of peer-mediated language interventions can benefit young patients with ASD. Further, adequate neuropsychiatric evaluation of this patient may yield successful and constructive changes to help mitigate oppositional behaviors that may be serving as roadblocks to successful speech and language therapy. Given these findings, two hours per week of speech therapy services are 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. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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 reimbursement for ConfirmMDx test for evaluation of the enrollee who has a history of elevated prostate specific antigen (PSA). Findings:  The 3 physician reviewers found that there is a lack of support in the current literature as to the superior efficacy of the services at issue in this patients case. Given the PSA rising in a short course and the equivocal but declining free PSA, a biopsy of the prostate was an appropriate choice to rule out prostate cancer. However, while the ConfirmMDx testing might affect a decision for repeat biopsy, there is a lack of medical evidence from the literature or clinical forum to indicate that there would have been an added benefit to the evaluation of this patient. As such, ConfirmMDx test was not likely to have been more effective for the evaluation of this patients medical condition than the available standard therapy. Final Result: The 3 reviewers determined that the services at issue were 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 urology 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 urology 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 urology 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

A 20-year-old female enrollee has requested for intravesical Botox injections for treatment of her neurogenic bladder and bowel.  Findings:  The physician reviewer found that the use of the InterStim device was the first significant advance for patients in this subset seen in many years. While the device does help a significant number of patients, some who have failed to achieve relief of symptoms with the InterStim device, appear to respond to the use of intravesical injections of Botox. The scientific literature demonstrates that some patients with urinary incontinence do receive benefit from Botox.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees knee pain.Findings:  The physician reviewer found that based upon a review of the literature and guidelines, they do not support viscosupplementation (Orthovisc injections) for more than two series for treatment of osteoarthritis of the knee. While this patient may have responded well to prior series of viscosupplementation injections, the clinical benefit of viscosupplementation for more than two series has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation is not U.S. Food and Drug Administration approved.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.