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

A 46-year-old female enrollee has requested a laparoscopic myomectomy for the treatment of her uterine fibroid. Findings:  The physician reviewer found that the laparoscopic approach for myomectomy is a medically appropriate option for this patient. The American College of Obstetrics and Gynecology (ACOG) notes that myomectomy may be an option for women who desire uterine preservation, and reports that laparoscopic myomectomy minimizes the size of the abdominal incision, resulting in a quicker postoperative recovery. ACOG reports that laparoscopic myomectomy results in less blood loss, reduced length of postoperative ileus, a shorter time to hospital discharge, reduced analgesic requirements and a more rapid recuperation. In this case, the pedunculated nature of the fibroid makes the patient a good candidate for laparoscopic removal because control of bleeding during the procedure can be more easily managed despite the size of the fibroid.In regard to the issue of the laparoscopic approach for larger fibroids, there is literature to support the expanding role of this procedure. Instrumentation for more efficient morcellization has been developed, and laparoscopic surgeons are gaining experience.  Walid and Heaton reviewed their 10-year experience with fibroids measuring up to 15.6 cm on preoperative ultrasound. No patient required conversion to the open technique.  Patients were discharged the day of surgery in the majority of cases. The 2008 article by Sinha and colleagues reviewed 505 laparoscopic myomectomies and concluded that laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number or location of the myomas. Thus, this patients fibroid is in the range that the literature indicates an experienced laparoscopic surgeon could manage. The decreased morbidity and the enhanced recovery associated with a laparoscopic myomectomy make this a medically necessary option for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A patient has requested reimbursement for the methylenetetrahydrofolate reductase (MTHFR) gene test, and the two common MTHFR variants, polymorphisms provided. Findings:  The physician reviewer found that the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Although there is a reported association between hyper-homocysteinemia and thromboembolic disease, studies involving testing for mutations or polymorphisms of the MTHFR gene have not yielded conclusive evidence that the findings will impact treatment decisions. The clinical utility of this test has not been established in any randomized clinical trial. Further, it is unlikely that MTHFR mutation testing would alter the management or therapy resulting in improved clinical outcomes. Long-term systemic anticoagulation would be indicated for the patient in any case. Therefore, the methylenetetrahydrofolate reductase (MTHFR) gene test, and the two common MTHFR variants, polymorphisms provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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: All three reviewers internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines recommend that RTC or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records indicate that this patient required a safe and stable living environment in order to develop recovery skills. Further, the records demonstrate that the patient meets the American Society of Addiction Medicine (ASAM) criteria, thus qualifying for ASAM Level III treatment, which is consistent with residential or inpatient treatment. Given that she met the these criteria, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Accordingly, the RTC services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested 12 units of Sumavel Dosepro per 30 days for treatment of her medical condition.   Findings:  The physician reviewer found that there is sufficient support for the requested medication quantity in this clinical setting.  Sumavel Dosepro is an effective migraine abortive medication.  However, headaches may return, and a second dose in 24 hours may be appropriate. Per the prescribing information, the maximum cumulative dose that may be given in 24 hours is 12 mg, two 6 mg injections separated by at least one hour.  Per the medical evidence, guidance to avoid medication overuse headache is that the patient should not treat more than two to three days per week on average with acute abortive medications.  Thus, the requested medication quantity is medically appropriate.  All told, 12 units of Sumavel Dosepro per 30 days is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested a second gastric bypass surgery (lap band surgery) for treatment of her obesity.  Findings:  The physician reviewer found that revisional bariatric surgery for inadequate weight loss is a controversial topic with poor evidence to support the different approaches. There are several small case series describing outcomes of laparoscopic adjustable gastric band placement following failed gastric bypass. In general, these case series are small retrospective reviews with limited follow-up (Vijgen, et al). The American Society of Metabolic and Bariatric Surgery published a review on endoluminal procedures to induce weight loss following bariatric surgery that determined these procedures were well tolerated with limited efficacy (Dakin, et al). Approximately 10% of primary bariatric surgical procedures will fail, and most of these failures will present as weight recidivism. Most of these patients fail to maintain weight loss for reasons that are not surgically correctable (De Gara and Karmali). For the reasons provided, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 45-year-old female with a history of a neck injury. She has subsequently experienced persistent neck and back pain. The patient tried multiple pain medications and received physical therapy, but continued to experience pain.  The patient has been using an RS-4i interferential stimulation device, which she reports has been effective. At issue is whether interferential stimulation is likely to be more beneficial than any available standard therapy.The RS-4i interferential stimulator remains investigational at this time. It is not widely used and has not been generally accepted as a suitable treatment option for painful neck and back conditions. There is insufficient evidence in the peer-reviewed literature demonstrating that the requested interferential stimulator is efficacious for patients such as this patient. Therefore, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.  The Health Plans denial should be upheld.Physician #2:  The patient is a 45-year-old woman with a longstanding history of neck and back pain. She has requested coverage from her Health Plan for an interferential stimulator that was prescribed in December 2005. The Health Plan has denied coverage for the device indicating interferential stimulation therapy is considered investigational.There is no Class I data to establish the efficacy of interferential stimulation for the treatment of neck and back pain. The device is not within the mainstream of care for orthopedic practice. Available data does not demonstrate an advantage to the RS-4i sequential stimulator over standard pain management modalities. Therefore, I have determined that the requested device 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 45-year-old woman with a long history of neck and back pain secondary to a neck sprain. She has attempted treatment with multiple conservative measures without sustained success. Her provider prescribed an interferential stimulator in December 2005 for pain management.  In February 2006 the patients provider noted improvement in her condition. The Health Plan has denied coverage for the interferential stimulation unit on the basis it is investigational in nature.The Health Plans denial should be upheld. The requested device remains of unproven efficacy in the treatment of musculoskeletal pain. There are no long-term, prospective studies to warrant its use in this clinical context.  Although the risks are minimal, the benefits have not yet been substantiated.  For these reasons, I have determined that the requested device 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female seeking bilateral breast reduction surgery. The patient has moderately hypertrophic breasts, but the anticipated volume is below the 5th percentile on the Schnur table. The plastic surgeons note describes conservative care, but no evidence documenting such care has been submitted. In addition, no evidence confirming a history of long-standing musculoskeletal pain has been provided.Due to the small volume to be resected, medical necessity for the proposed breast reduction cannot be established. This patients history of back, shoulder and neck pain are consistent for symptomatic macromastia; however, no objective evidence verifying this history has been submitted. Photocopies of photographs confirm moderately large, ptotic breasts. The proposed resection of 275 to 350 grams per breast is quite small and may not correct the patients symptoms. According to Schnur, et al., a breast reduction of 575 grams per side for this patient would be required to meet the 22nd percentile for weight of reduction. In Schnurs study, resection weights above the 22nd percentile indicated that the patients motivation is purely medical. The planned resection of 275 to 350 grams for this patient is below the 5th percentile guideline of 367 grams per breast. According to the Schnur data, this would indicate the procedure is not medically necessary. While the question of what volume of resection is adequate to correct patient symptoms remains controversial, the Schnur data would suggest that the planned reduction is small enough that the procedure should be considered cosmetic. Based upon accepted criteria, a breast reduction of 275 to 350 grams per breast would not be considered medically necessary for this patient. Furthermore, in the absence of any documentation confirming a history of long-standing musculoskeletal pain and the failure of conservative care, authorization of the requested procedure cannot be justified.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intravenous (IV) Remicade infusions. Findings:  The physician reviewer found that the request for IV Remicade infusions has been established as medically necessary for treatment of the patients juvenile spondyloarthritis. The patient has been treated with NSAIDs, methotrexate, and Humira. The patient did respond to Humira initially but then lost response. The provider recommends Remicade infusions to treat the patients inflammatory arthritis. Remicade is indicated for children with Crohns disease, thus supporting its safety in the pediatric population. There are additional studies indicating that Remicade is safe in juvenile arthritis. Remicade is also indicated for adult ankylosing spondylitis, which is the same category of arthritis as this patients disease. The efficacy and safety of Remicade in ankylosing spondylitis is well established. For juvenile spondyloarthritis, Remicade has demonstrated a significant improvement in arthritis, enthesitis, inflammatory markers, pain, and physical function. In this case, the patients inflammatory disease will likely respond to Remicade, and is medically necessary for prevention of long-term damage that may result from untreated inflammatory arthritis. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in pediatric rheumatology 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:   An enrollee has requested Lyrica for treatment of his medical condition.  Findings:  The physician reviewer found that Lyrica has a U.S. Food and Drug Administration (FDA) indication for treatment of fibromyalgia. In the medical literature, Pauer and colleagues reported that Lyrica demonstrated modest efficacy in pain, global assessment, and function in patients with fibromyalgia at 450 mg per day, and improved sleep across all dose levels, but it did not provide consistent evidence of benefit at 300 and 600 mg per day in this study.  Mease and colleagues noted that patients in all Lyrica groups showed statistically significant improvement in endpoint mean pain score and in patient impression of global change (PGIC) response compared with placebo. Compared with placebo, all Lyrica treatment groups showed statistically significant improvement in assessments of sleep and in patients impressions of their global improvement. However, this patients medical records do not support a diagnosis of fibromyalgia or indicate any other neuropathic pain condition. As such, the requested Lyrica is not supported as 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 with sub-specialty certification in pain 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for Benlysta that was denied by the health plan as not medically necessary. A review of the medical records indicates the patient with systemic lupus erythematous was seen by her rheumatologist.  She was having a mild flare in symptoms and wanted to re-start the medication.  Physical examination showed slight tenderness over some joints, no acute synovial swelling or effusion and good range of motion.  There was no evidence of rashes.  Labs results showed a negative double-stranded antibody and negative Smith antibody. According to the medical literature, serologically positive systemic lupus erythematosus (SLE) patients responded favorably to treatment with belimumab plus standard of care therapy. This is consistent with the phase III belimumab trials.  There is no documentation of any positive autoantibodies or low complement levels.  Thus, there is no evidence of active lupus to the extent that would require use of Benlysta based on the data available in the time frame under review.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Rheumatology 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Propel sinus implant. Propel sinus implants are now considered an adjunct to the healing properties after routine endoscopic sinus surgery and many reports attest to the benefit of the healing and absence of scar formation. However, there is a lack of long-term clinical trials to demonstrate the benefit of the Propel sinus implant. A study reported that there were unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with chronic rhinosinusitis undergoing functional endoscopic sinus surgery. Future, high-quality randomized controlled trials are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents. Given these findings, the Propel sinus implant was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Propel sinus implant was 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 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:  One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology 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: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the gene panel testing for evaluation of the enrollees major depressive disorder, recurrent, moderate. Findings:  Three physician reviewers found that genetic testing was recommended in this case since the patient reportedly had adverse effects from SSRIs. The records provided for review did not specify which medications in the SSRI class were attempted, or what medications in other classes were tried and the outcomes. The Genecept report showed a broad range of medications which may be successful in treating this patients conditions. However, studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. Currently, there is a lack of large randomized trials supporting its use in this clinical setting. The existing studies suggest that there was no significant correlation between either genotypes or medication serum concentration and response treatment. Given these findings, the gene panel testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 psychiatry 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.