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

The parent of an 11-year-old female enrollee has requested a tonsillectomy and adenoidectomy for the treatment of the enrollees chronic tonsillitis. Findings:  The physician reviewer found that clinical indicators for tonsillectomy with or without adenoidectomy include three or more infections of tonsils and/or adenoids per year despite adequate medical therapy, hypertrophy causing dental malocclusion or adversely affecting orofacial growth, hypertrophy causing upper airway obstruction/severe dysphagia/sleep disorders/cardiopulmonary complications, peritonsillar abscess unresponsive to medical management, chronic or recurrent tonsillitis associated with the streptococcal carrier state not responding to antibiotics, and unilateral tonsillar hypertrophy presumed neoplastic. According to the standard of care established by the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS), adenotonsillectomy is medically necessary for treatment of this patients chronic tonsillitis, because she has had three episodes of tonsillitis in the past 10 months. The proposed tonsillectomy with adenoidectomy is medically appropriate and indicated in this case and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Lamictal for treatment of the enrollee who has a history of epilepsy. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the medical necessity of the requested medication in this clinical setting.  Several recent studies have examined the question of brand versus generic antiepileptic medication regimens. The medical literature that has compared common generic lamotrigine to the brand name Lamictal in patients with epilepsy showed that generic and brand bioequivalence are similar. The studies have shown that patient pharmacokinetic ratios support average bioequivalence public standard. A recent study performed also specifically looked at Lamictal and their study supports the evidence that the lamotrigine and Lamictal are bioequivalent when tested in patients with epilepsy. Additionally, the American Epilepsy Society Position states, The American Epilepsy Society (AES) recognizes that well-designed, prospective studies of generic antiepileptic drug (AED) substitution have been completed. Two studies demonstrated bioequivalence of generic products in patients with epilepsy taking concomitant AEDs. Additionally, an analysis of Abbreviated New Drug Application data suggests that generic products of branded modified-release products (e.g., extended release, delayed release) are bioequivalent and safely interchangeable. Results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. In this patients case, this is the first time this patient will be taking Lamictal. The records do not indicate that the patient has tried a generic formulation of Lamictal. Based on the medical evidence and the documentation provided, Lamictal is not medically necessary for the treatment of this patients medical condition. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rhizotomy (radiofrequency neurolysis of the left-sided facet joints at L3-S1). Findings:  The physician reviewers found that lumbar medial branch radiofrequency ablation or neurolysis has been demonstrated to be effective in well selected patients with chronic low back pain due to lumbar facet pain. Medial branch radiofrequency neurotomy in the lumbar spine can produce results that last from months to one year. This patients provider noted that he is sure that the facets on the left is the patients pain generator without having to repeat medial branch blocks. With the prior success of radiofrequency ablation on the left side from L4 to S1, the requested rhizotomy (radiofrequency neurolysis of the left-sided facet joints at L3-S1) is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two of the three reviewers determined that the requested service is 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:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is 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: 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, while her breasts are not reported to be especially dense, there are two reasonable indications for tomosynthesis.  First, the new mass that was discovered in the lower outer aspect of the left breast was an appropriate indication for breast tomosynthesis.  Second, the area of asymmetry is another indication for breast tomosynthesis.  In sum, digital breast tomosynthesis was likely to have been of greater benefit 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

The patient has requested reimbursement for residential mental health services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guideline, this patient did not meet the criteria for the residential mental health services. The records provided for review document that the patient was at some risk of harm, as he had passive suicidal ideation without active urges or intent. The patient demonstrated some functional impairment to social isolation and inability to complete his graduate school studies. The patient had minor comorbidities, including neuropathic pain from lichen sclerosis for which he was taking gabapentin and Tylenol with codeine. The patient had minimal medication changes during his stay. The patients recovery environment was mildly stressful. The patient lived with his father, who was involved and supportive with his treatment. The patient initially demonstrated poor response to treatment, with improvement in mood and functioning by the end of his admission. The patient demonstrated optimal engagement as reported by the providers. The patients composite score is 13, which is consistent with recovery maintenance health management. Given these findings, the residential mental health services were not medically necessary for treatment of this patient.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 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: The patient has requested reimbursement for the gene test (Foundation One) for evaluation of the enrollees head and neck squamous cell carcinoma. Findings:  The physician reviewer found that Foundation One 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 Foundation One assay adds to decision making ability, or yields a result that is reliably 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 (Von Hoff, et al). 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. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 62-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation of her medical condition.   Findings:  Three physician reviewers found that this patient has a 7.7% lifetime risk of breast cancer, which is well below the threshold for significant increased risk and qualification for screening MRI.  The mammogram report did not indicate that the benign nodule required additional imaging such as ultrasound.  If there is concern regarding the nodule, MRI is not indicated for further investigation and biopsy would be the only additional test to provide a diagnosis.  The use of MRI of the breasts in this clinical setting falls outside of the usual and customary guidelines as recognized by the American Cancer Society and the American College of Radiology.  All told, the requested MRI of the breasts is not likely to be of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested for Oxycontin 80 mg for treatment of her bilateral sciatica and spondylosis.  Findings:  The physician reviewer found that the medical literature reports that high-dose opioids may also cause adverse outcomes including those noted by Baron and McDonald in their 2006 study. The authors concluded that high-dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Further, Ballantyne and Mao reported on studies demonstrating that prolonged use of high-dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The authors noted the goal of practice guidelines is to protect patients from the adverse effects of opioid therapy, and presently, Oxycontin 80 mg, twice daily is the maximum recommended dosage. This patient reported a 5 of 10 VAS pain level with her current medication regimen, including Oxycontin 80 mg, 3 times per day. Consistent with the scientific data, the requested dosage of Oxycontin is not indicated given that she continues to carry a significant level of pain, and has not demonstrated any increase in function.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that  breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is insufficient peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, the breast tomosynthesis performed was not likely to be more beneficial for evaluation of this patients condition than standard modalities. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are 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 68-year-old female enrollee has requested the medication Lunesta for treatment of her insomnia. Findings:  The physician reviewer found that newer agents for insomnia have been shown to be more effective and cause fewer side effects than benzodiazepines and other older agents. One such newer agent is zolpidem. Zolpidem is not indicated for long-term use and has been shown to cause headaches, dizziness, and tiredness in the daytime (Lieberman). Another new agent is eszopiclone. Eszopiclone has the longest half life of the newer sleep agents and can last from 7 to 9 hours in duration in the patients age group. It is unique in that dependence does not develop, and most experts believe it is safe and effective for long-term use. Improvement in quality of life and improved job performance has been seen in studies lasting six months for both eszopiclone and long-acting zolpidem (Walsh and colleagues). In summary, given this patients co-morbid conditions (trigeminal neuralgia, ocular migraine, and chronic major depression), the poor results she obtained with trazodone and standard release generic Ambien (zolpidem) and the data from peer reviewed clinical trials on Lunesta and its long half life as well as its effectiveness for the  long-term treatment of insomnia, Lunesta is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male with mobility limitations and a weight of 414 pounds or greater.  The Health Plan authorized a power-operated vehicle (POV) for him.  The patient has specifically requested the Pride Maxima 4-Wheel Heavy-Duty Scooter, but the Health Plan determined the Sprinter Jumbo 3 power scooter was a better choice for this patient because it has a greater maximum weight capacity (500 pounds vs. 450 pounds).  The Health Plan has denied the patients request for the Pride Maxima scooter asserting it is not medically necessary that the patient have this particular model of POV.I have reviewed the records provided and am aware that there are varying reports of the patients weight.  He himself reported a weight of 449 pounds in a letter written in August 2005.  His lowest recorded weight was 414 pounds in October 2005, as noted by his primary care provider. The exact weight of the patient is not as significant as the fact that his weight fluctuates significantly. When you consider a weight delta of 35 pounds over a period of approximately two months, a POV with a weight limit of only 450 pounds is not appropriate.  I concur with the Health Plans determination that a POV with a 500-pound weight capacity is the more appropriate selection for this patient.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested for the Medtronic MiniMed Insulin infusion pump and necessary supplies for treatment of his diabetes. Findings:  The physician reviewer found that this is a patient with uncontrolled diabetes mellitus type 2.  His glucose monitoring records indicate that the patient has dawn phenomenon and unpredictable postprandial control. He has seen his medical provider at least three times in the past year, and he has attended diabetes education program. The patient is injecting multiple doses of insulin, and he has been testing three to four times a day, as documented by the submitted medical records.  This patient will benefit from the insulin pump.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neratinib 240 mg (six 40 mg pills) by mouth, daily for one year for treatment of the enrollee who has a history of stage III left breast cancer. Findings:  The physician reviewer found that there is support for the requested medication in this clinical setting. Per the National Comprehensive Cancer Network (NCCN) guidelines, neratinib may be considered as extended adjuvant therapy following adjuvant trastuzumab containing therapy in HER2 positive patients with a perceived high risk of recurrence such as stage II-III. This patient fits the criteria recommended by NCCN guidelines. Additionally, in a study by colleagues, they found that neratinib significantly improved two year invasive disease free survival when given after chemotherapy and trastuzumab based adjuvant therapy to patients with HER2 positive breast cancer. Moreover, the package insert states that neratinib is indicated for the extended adjuvant treatment of adult patients with early stage HER2 disease to follow adjuvant Herceptin based therapy. For the reasons mentioned above, the requested neratinib 240 mg (six 40 mg pills) by mouth, daily for one year is medically necessary for the treatment of this patients medical condition. 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 medical oncology 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 45-year-old male enrollee has requested an office visit and laboratory services for an evaluation of his medical condition. Findings:  The physician reviewer found that the patient has a history of hyperlipidemia and thus the lab tests to check his cholesterol levels were appropriate. Lipoprotein testing is also appropriate and indicated in patients with elevated low density lipoprotein cholesterol to further define a patients cardiovascular risk, in order to determine how aggressive their medical treatment needs to be (Katsouras and colleagues). In addition, a comprehensive metabolic panel is justified to monitor a patients baseline liver function prior to initiating, or while a patient is on statin therapy. In addition, because this patient has a history of anemia and fatigue, all of the following lab tests were medically necessary; complete blood count; thyroid; ferritin; vitamin B12 level; LDH, and; the DHEA testing. However, homocysteine testing (CPT 83090) was not indicated as the patient does not have a history of coronary artery disease, and there is inadequate evidence to suggest that screening and/or treatment of low homocysteine levels results in any clinical difference (Lentz and Haynes). In addition, there is no clear clinical indication for the uric acid testing (CPT 84550) or the phosphate testing (CPT 84100) based on the records provided. Therefore, these tests were not medically necessary.