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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series (CPT J7324) in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited based on the available documentation. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. For these reasons, the requested Orthovisc injection series (CPT J7324) in both knees is 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 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: An enrollee has requested authorization and coverage for Zepatier 1 tablet daily for 12 weeks. Findings:  The physician reviewer found that according to the most 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. 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. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Accordingly, treatment with Zepatier 1 tablet daily for 12 weeks 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for blood glucose monitor and sensors. The records provided for review document that this patient presents with prediabetes. The U.S. Food and Drug Administration (FDA) approved the Freestyle Libre flash glucose monitoring system to monitor interstitial glucose concentration without obtaining a capillary blood sample from the fingertip for management of type 1 and type 2 diabetes in adult patients (Moser, et al.). While studies have aimed to assess the efficacy of the Freestyle Libre system for patients with prediabetes, this device is not recommended for this patient population (Whelan, et al.). Therefore, the requested blood glucose monitor and sensors are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in diabetes, 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: Upheld

A 65-year-old female enrollee requested the Lariat procedure for medical treatment of her atrial fibrillation.  Findings:  Two physician reviewers found that the requested procedure is not likely to be more effective for this patient than other available options. The requested procedure is not supported by the medical literature given the lack of long-term studies demonstrating its safety and efficacy. In addition, it is not clear, based on the existing data, whether the Lariat device lowers stroke risk (January, et al). In this case, there is also the possibility that the patient may be able to tolerate less intensive anti-coagulation with anti-platelet therapy. Based on the medical literature cited above and the documentation submitted for review, the requested Lariat procedure is not likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 32 to 40 hours per week of in home skilled nursing services from a registered nurse (RN) and 12 hours per week of in home skilled nursing services from a licensed vocational nurse (LVN) for treatment of the enrollees cerebral palsy, epilepsy, dependence on supplemental oxygen, and legal blindness. Findings:  The physician reviewer found that the patients medical history includes high risk of aspiration, requirement of gastrostomy tube feedings, respiratory suctioning and treatments, skin care, and seizure monitoring. Enteral feeding and the patients respiratory suctioning are skilled nursing needs that require skilled nursing rather than a home health care provider to ensure continuity of care and effective treatment. The patient requires ongoing supervision that can be met from a long-term care facility or after intense family training by 24-hour family support. The family of this patient will need skilled nursing services to establish a safe and effective maintenance program if the patient is stable to be transitioned to 24-hour family support after the family has had proper training. Skilled nursing is typically an intermittent service that is provided less than seven days per week and less than eight hours per day. This treatment will allow assessment of patient stability and ability of family to be trained and/or care for patient in a proper and effective manner. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings: Three physician reviewers found that currently, Harvoni is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic hepatitis C genotype 1 infection in adults. In this patients case, there is documentation of hepatic fibrosis at Metavir F2. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines define patients with Metavir F2 fibrosis staging as High Priority for hepatitis C virus eradication. Given this support, this patient meets the classification per AASLD/IDSA guidelines as High Priority for treatment. All told, the requested Harvoni is supported as medically necessary. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

This patient is a 44-year-old man diagnosed with chronic lymphocytic leukemia (CLL) in April 2000. He was initially treated with chemotherapy from February through May 2002 with a good response. He was found to be ZAP-70-positive, which is an unfavorable prognostic marker and accordingly, he began more intensive chemotherapy in 2005, again with a good response. A bone marrow aspirate in November 2005 showed only minimal residual disease. The patient has sought several medical options, and now wishes to have consolidation therapy with alemtuzumab (Campath) in an effort to eradicate the minimal remaining leukemia cells in his bone marrow.  The Health Plan has denied the patients request for authorization based upon a determination that consolidation therapy with Campath (alemtuzumab) is not medically necessary.The treatment of very minimal residual disease in patients with CLL is a controversial topic and the subject of several ongoing clinical trials. A variety of treatments have been utilized in an effort to eradicate residual disease from the bone marrow.  In this particular case the treatment under consideration is alemtuzumab, a monoclonal antibody. A recent study by Moreton, et al. strongly suggests that in a small number of patients, alemtuzumab can indeed eradicate minimal residual disease and that this therapy is associated with prolonged survival. Reviews on this topic have recently appeared in Seminars in Oncology and data on the use of alemtuzumab in this setting is very encouraging. All in all there is sufficient data to conclude the patient is likely to experience meaningful clinical benefit from consolidation therapy with Campath (alemtuzumab).Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her back pain.   Findings:  The physician reviewer found that based on review of the available records, the patient presents with low back pain. However, there are no documented signs or symptoms of concern, such as neurological deficit, infection, cancer or radicular pain that would necessitate an MRI of the lumbar spine. Physical therapy has been ordered but the patient has not reportedly attended the program. Consistent with the American College of Radiology (ACR) criteria, this patients medical condition is not an indication for the requested MRI of the lumbar spine.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block therapy.Findings:  Three physician reviewers found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. This patient has been diagnosed with occipital neuralgia on examination. There are several options for management of occipital neuralgia, including antiepileptic drugs as well as tricyclic antidepressants, which the patient has not tried per the submitted documentation. The medical evidence has not established that occipital nerve block therapy was likely to have been more beneficial for the treatment of this patient than other available standard therapy. In sum, occipital nerve block therapy was not likely to have been superior over other available treatment options. Final Result: The 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: 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: Upheld

A 50-year-old male enrollee requested authorization and coverage of verapamil for the treatment of peyronies disease.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Victoza 1.2 mg subcutaneously every day. Victoza is glucagon-like peptide-1 (GLP-1), a multifaceted hormone with broad pharmacological potential. Researchers noted,  Among the numerous metabolic effects of GLP-1 are the glucose-dependent stimulation of insulin secretion, decrease of gastric emptying, inhibition of food intake, increase of natriuresis and diuresis, and modulation of rodent -cell proliferation. While GLP-1 receptor agonists (GLP-1RAs) have already proven to be an efficient treatment option for type 2 diabetes, researchers conducted a meta-analysis which supported the use of GLP-1RAs in treating patients with type 1 diabetes. In this case, the patient has type 1 diabetes and has responded well to Victoza in the past. Therefore, Victoza 1.2 mg subcutaneously every day is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries (repair brow ptosis; reduction forehead contour and graft; reduction of facial bones) for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. Although this patient has documented gender dysphoria, the requested services are based on aesthetic goals. Based upon the documentation provided, there appears to be slight brow ptosis, mild frontal bone projection and a relatively wide appearing face.  However, these findings are relatively gender neutral. Therefore, this is not atypical for a female appearance. There is a lack of evidence to indicate a clearly masculine appearance of the brows, forehead and facial bones. Based on the submitted documentation, the patient has findings of the brows, forehead and facial bones which are more consistent with a relatively normal appearance for a female. Therefore, the medical necessity of the requested services for treatment of the patients gender dysphoria has not been established. With regard to whether the requested services are considered reconstructive in nature, the first criterion that must be met is whether the patients facial features represent an abnormal structure. There is a wide spectrum of facial appearances that can be consistent with typical female appearances. This patient has a normal facial appearance that is not gender specific for the brows, forehead and facial bones. The patients brows, forehead and facial bones appear within the norm for a typical female. As such, the patients facial features are not considered abnormal for a person of the female gender. All told, the requested facial feminization surgeries (repair brow ptosis; reduction forehead contour and graft; reduction of facial bones) are not reconstructive in nature for the treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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 has requested authorization and coverage for Xifaxan 550 mg. This patient has symptoms and testing consistent with small intestinal bacterial overgrowth, and symptoms can improve with treatment. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. Per the medical literature, Xifaxan has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. As noted by Achufusi and colleagues, Xifaxan has emerged as the preferred agent among clinicians for the treatment of small intestinal bacterial overgrowth. The dose and duration of 550 mg three times daily for 14 days is consistent with regimens used in studies, which vary widely. There is sufficient support for the requested medication in this clinical setting. Therefore, Xifaxan 550 mg 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either class 1 or class 2, representing the individual risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients who had undergone sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma classification can be used to make clinical decisions. Therefore, the superior efficacy of DecisionDx-Melanoma assay has not been established. Final Result: The 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 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: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested positron emission tomography (PET) scan and a single photon emission computed tomography (SPECT) for evaluation of his personality changes, persistent insomnia and mood changes.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature there is a paucity of scientific data supporting the clinical utility of either PET or SPECT imaging in the evaluation of this patient with ADHD and personality issues. There is a lack of evidence that PET or SPECT imaging is within the standard of care over standard available alternatives. All told, the diagnostic procedures at issue were not likely to have yielded additional information helpful in evaluating and treating this patients medical condition.