Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for emergency medical services. As noted in the medical literature, surgical repair in this clinical setting results in significantly better subjective outcomes than non-surgical management. Similarly, acute surgical repair has shown improved patient satisfaction, pain relief, and endurance, as well as reduced risk of complications and re-rupture when compared to chronic repair. In this case, the patient presented with an emergency condition necessitating surgery before shortening and atrophy of the avulsed muscles occurred. The diagnostic work-up and location of a specialist were necessary to assess the feasibility of surgical repairs and perform the procedure. Although these factors resulted in a delay, it did not make the surgical procedure any less of an emergency situation. Thus, the emergency medical services provided were provided for treatment of an emergency medical condition. Final Result: The reviewer determined that the services at issue were necessary for treatment of an emergency medical condition. Therefore, the Health Plans denial should be orthopedic surgery. 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 Harvoni for treatment of her hepatitis C virus. Findings: The physician reviewer found that in the past, treatment for patients with early stage hepatitis C virus was delayed in order to wait for more effective, less toxic treatment. This has now changed with the introduction of Harvoni, which is a once daily pill that is used without ribavirin and has no serious adverse effects or contraindications. The U. S. Food and Drug Administration label is clear regarding Harvonis approved use, which includes early stage disease. This is exactly the case for this patient who should be treated even though she does not present with advanced liver disease. Moreover, the position of American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommends that all patients with chronic hepatitis be treated except those with limited life expectancy of 12 months or less due to a non-liver related condition. Therefore, the requested Harvoni is medically necessary for 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a dotatate positron emission tomography (PET) scan. Recurrence of neuroendocrine tumors after resection is common, even more so in cases with nodal metastases. Early detection of tumor recurrence is critical to determine treatment planning. Currently, there is a lack of consensus for follow-up imaging of neuroendocrine tumors for the detection of recurrence. However, dotatate PET imaging has become increasingly used for the monitoring of certain neuroendocrine tumors, specifically somatostatin receptor imaging. In correlation with tumor biomarkers, dotatate PET can help determine the presence of recurrence. This patient has elevated tumor biomarkers as well as symptoms, which may suggest recurrence. Conventional computed tomography (CT) is nonspecific and would be less likely to differentiate post-surgical changes from tumor recurrence. The National Comprehensive Cancer Network (NCCN) guidelines suggest that dotatate PET can be useful in this clinical setting. Therefore, the requested dotatate PET scan is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

An enrollee has requested authorization and coverage for hyaluronan injections in both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited, as he has tried and failed other conservative treatments, including repetitive corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Under these circumstances, hyaluronan injections in both knees are medically necessary to treat 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 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 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.  This patient should be considered treatment naive as the prior regimen was interferon three times weekly and ribavirin rather than a full course of PEG-interferon and ribavirin.  The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret 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

The patient is a 33-year-old male with a history of amphetamine abuse, smoking on average two to three times per month. His provider referred him for residential treatment. The patient is employed, married, and in no legal difficulty related to amphetamine use. In addition, the patient appears motivated for treatment. His Health Plan has declined authorization for residential treatment and has recommended outpatient therapy.The Health Plans denial should be upheld. Because of the patients rather infrequent rate of drug use as well as his motivation for treatment, outpatient therapy would be the treatment of choice for this patient. He has not previously had any concerted outpatient treatment and is otherwise a sufficiently healthy candidate for outpatient treatment. Based upon this information, there is no evidence the patients drug use warrants the intensity of residential treatment or that outpatient treatment will not be successful. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Strensiq (asfotase alpha) 80 mg/0.8 mL vials = 9.6 mL (12 vials) x 28 days, and Strensiq (asfotase alpha) 80 mg/0.45 mL vials = 5.4 mL (12 vials) x 28 days. Findings:  The physician reviewer found that submitted documentation does not support the medical necessity of the requested medication, which is used to stabilize skeletal abnormalities, and is not indicated for chronic pain. The records did not demonstrate clinical signs and/or symptoms of hypophosphatasia, such as skeletal deformities or juvenile onset, or a diagnosis confirmed by the presence of a known pathological mutation in the ALPL gene, or of skeletal abnormalities demonstrated on radiographic imaging. In this case, while the patient has chronic pain, the records do not document a history of juvenile onset or of recurrent fracture. Therefore, Strensiq (asfotase alpha) 80 mg/0.8 mL vials = 9.6 mL (12 vials) x 28 days, and Strensiq (asfotase alpha) 80 mg/0.45 mL vials = 5.4 mL (12 vials) x 28 days are not medically necessary for the treatment of this patientFinal 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 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 Otezla for treatment of her medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Otezla (apremilast) is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis, but it is not currently known to be disease modifying at this time.  As such, it is not a preferred agent for the treatment of psoriatic arthritis (Gossec, et al). In this case, the patient has evidence of psoriasis and psoriatic arthritis.  In addition, the patient does not have any contraindications to the formulary preferred medications. Given the above, the requested medication is not medically necessary for treatment of the 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 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: The patient has requested authorization and coverage for Divigel. While transdermal estrogen is a preferred formulation for the delivery of hormone replacement therapy in symptomatic postmenopausal women, there are many effective treatment options. There are many transdermal formulations of estrogen for this clinical indication. Divigel is not the only product available. However, there is no preferred product in the current medical literature. This patient has tried Femring, which is a low estrogen dose for symptoms of vaginal dryness. She has also tried estrogen pellets, which are not a U.S. Food and Drug Administration (FDA) approved treatment. The records do not document an adequate trial and failure, or contraindication to, one of the Health Plans formulary alternatives. The Health Plans formulary alternatives are likely to be at least as effective as Divigel. Therefore, Divigel is not medically necessary for treatment of this patient. 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 obstetrics and gynecology 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 authorization and coverage for brand name medication, Wellbutrin XL (extended-release tablet). In a randomized clinical trial testing the bioequivalence and therapeutic equivalence of generic bupropion XL 300 mg to the brand product, researchers concluded that three bupropion XL 300 mg generic products were both bioequivalent and not therapeutically different from the brand drug and from each other. In this case, notes reported a diagnosis of major depressive disorder, treated with bupropion XL 150 mg daily. The patient reported a lack of improvement and no side effects. Notes reported that the patients dosage was increased to bupropion XL 300 mg daily. In an application for independent medical review, the patient reported having tried three different forms of generic Wellbutrin and experiencing side effects and a lack of improvement in symptoms. Despite being requested, the submitted records did not document if the patient underwent standard treatment with selective serotonin reuptake inhibitors (SSRI) as first-line therapy. In this case, given this patients sensitivity to medications and lack of remission, augmenting bupropion with a SSRI or switching therapy to a SSRI or serotonin and norepinephrine reuptake inhibitors (SNRI) would be recommended over the requested medication. Therefore, the brand name medication, Wellbutrin XL (extended-release tablet), is not likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested brand name medication, Wellbutrin XL (extended-release tablet) is 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 requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry and in preventive medicine and is 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: Overturned

A 42-year-old female has requested testing with the Bravo pH Monitoring System for the evaluation of gastroesophageal reflux disease (GERD).  Findings:  Three physician reviewers found that wireless esophageal pH monitoring (Bravo) was approved by the FDA in 2002 for the evaluation of the patient with GERD. The Bravo Esophageal PH monitoring system is now considered the standard of care for the evaluation of patients with suspected or possible gastroesophageal reflux disease (GERD). With this system, there is now the ability to perform 48-hour wireless capsule pH monitoring. This is considered a major advance in patient comfort and acceptance, while providing the opportunity to gather an additional day of monitoring. Such monitoring is the single best way to evaluate patients for the presence of abnormal esophageal acid exposure or reflux, to determine whether reflux is occurring during the day or night, and to correlate the presence or absence of reflux with continuing symptoms. Compared to catheter probe monitoring study, it does not cause inconvenience, discomfort and does not interfere with day to day activities during the duration of the monitoring.  Therefore, it has replaced the catheter based system nationally and has become the standard of care for the evaluation of suspected GERD. Based upon the studies published in the peer reviewed journals, Bravo PH monitoring is considered safe and efficacious for the evaluation of patients with GERD or with extraesophageal manifestations of GERD. In various studies the comparison of the 24-hour pH probe to the Bravo 48-hour period has clearly indicated that the 48-hour pH capsule is superior to the 24-hour pH capsule probe for a variety of reasons. The Bravo pH capsule allows collection of data over a 48-hour period as opposed to a 24-hour period. The 48-hour period pH capsule is a physiological measurement of acid reflux. Unlike catheter probe system, the wireless capsule does not cause inconvenience and discomfort to the patient, does not limit day to day activities or food intake and gives more accurate evaluation of the patient's underlying GERD.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested Vital Stim therapy for the treatment of the enrollees anoxic brain injury. Findings:  The physician reviewer found that in the medical literature there is relatively strong evidence that Vital Stim therapy is beneficial in the stroke population. The most recent randomized clinical trial is from Permsirivanich and colleagues who found superior improvement in patients treated with neuromuscular electrical stimulation in lieu of rehabilitation therapy alone. In addition, Christiaanse and colleagues documented the safety and benefit in children treated with Vital Stim when compared to standard therapy. The use of Vital Stim for this patient with cerebral palsy is medically indicated. The possibilities include potential removal of the tracheostomy with secondary improvement in saliva control, and/or removal of the G-tube with improvement in independence with feeding which would enhance life expectancy. Thus, the proposed Vital Stim therapy is medically appropriate and indicated for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested Lexapro for the treatment of her depression. Findings:  The physician reviewer found that Lexapro has been effective and helpful for this patient and she appears to be compliant with it, and free of side-effects from it. The Health Plans alternative therapy recommendation is Celexa, which is known to have more side effects (e.g., somnolence and daytime fatigue) than Lexapro. Lexapro is a superior agent for side-effect sensitive patients such as this one. The patient in this case would most likely relapse rapidly if forced to return to generic citalopram (Celexa).
Appeal type: Experimental/Investigational
Decision: Overturned

A 71-year-old female enrollee has requested PET/CT scan skull-thigh for evaluation of her biliary cancer.  Findings:  Three physician reviewers found that the records provided for review suggest the requested PET/CT is being requested to stage the patients cancer. PET/CT scans have become widely used in various cancer types as an aid in determining the precise extent and stage of a patients cancer. Further, there is adequate data that PET/CT scanning is useful in biliary duct carcinoma (Delbeke, et al; Anderson, et al). Therefore, the requested PET/CT scan is likely to be more beneficial for evaluation of this patients medical condition than standard alternatives in determining the extent of disease and for radiation planning.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the special blood test CPT code 81422.Findings:  The physician reviewer found that the special blood test, CPT code 81422 performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin for screening for fetal aneuploidy A microdeletion syndrome is caused by a chromosomal deletion encompassing contiguous genes that is too small to be detected by conventional cytogenetics. Given the rarity of these disorders, it is uncertain what a positive or negative screening test result means. Cell free DNA screening tests for microdeletions have not been validated clinically and are not recommended at this time. For women who wish to know whether their fetus has a microdeletion, the best option is to undergo prenatal diagnostic testing with microarray of fetal cells from [chorionic villus sampling] CVS or amniocentesis. As such, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1,2 & 3 are  board certified in obstetrics and gynecology 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.