Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has requested authorization and coverage for high intensity focused ultrasound (HIFU). This patient has a history of prostate cancer and a rising prostate specific antigen (PSA). Treatment has included radiation therapy and brachytherapy. A computed tomography (CT) scan revealed no evidence of metastasis. Biopsies demonstrated local recurrence. His provider has recommended treatment with HIFU. The National Comprehensive Cancer Network (NCCN) guidelines support HIFU for treatment of patients with radio recurrent prostate cancer. In addition, one recent study reported that treatment with HIFU has comparable outcomes to modalities such as surgery and cryotherapy with an acceptable side effect profile. Given this support, HIFU is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested for an osteochondral knee allograft for treatment of her right knee pain and chondromalacia.    Findings:  Two physician reviewers found that an article by Bugbee and Convery as well as an article by Gross, et al. attest to the effectiveness of osteochondral grafting. The patients age and her failure to respond to all available conservative treatment options to date (except joint replacement) support the conclusion that the requested osteochondral allograft is appropriate and likely to be more efficacious than standard therapy in this particular case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  In sum, Afirma Gene Expression Classifier testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three reviewers determined that the services at issue were 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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

The patient is a 53-year-old woman with more than a 20-year history of diabetes mellitus type 1. The submitted documents indicate the patient utilized a MiniMed 507c insulin pump for over four years. In May 2003, the patient requested a new pump because of concern over accuracy of her current pump. In April 2003, the patients A1c was 8.9% suggesting that the patient was not in good glycemic control. In November 2003, the patients provider indicated that the patient was going to stop the pump and switch to multiple dose injections (MDI). Self-monitored blood glucose values from October 2003 to November 2003 while the patient was still on pump therapy compared to November 2003 to December 2003 values while the patient was on MDI showed no changes in her blood glucose control; an A1c in December 2003 was still 8.9%. The patients provider has recommended a Medtronic Paradigm insulin pump. The Health Plan has denied authorization for the requested equipment on the basis that it is not medically necessary.The patient has poorly controlled type 1 diabetes mellitus. While on MDI the patients A1c was greater than 7% and she had wide fluctuations in her blood glucose levels. Use of an insulin pump is the appropriate standard of care for patients such as this patient and is consistent with current medical literature as well as the guidelines set forth by the American Diabetes Association. However, there is no evidence that a Medtronic Paradigm insulin pump is medically indicated. The patient should receive a standard replacement pump similar to one that was previously authorized. In addition, the patient should take advantage of recommendations of the Health Plan for managing all aspects of her diabetes.Based upon the information set forth above, I have determined that a Medtronic Paradigm insulin pump is not medically necessary for treatment of the patients medical condition; however, a standard insulin pump is medically necessary. Therefore, the Health Plans denial should be partially overturned. A standard insulin pump should be authorized for the patient.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested mental health outpatient services for treatment of her major depressive disorder. Findings:  The physician reviewer found that the mental health outpatient services provided on the specified dates were medically necessary for treatment of the patients medical condition. The patient received psychotherapy previously for mood symptoms with good effect. In the month and year indicated, the provider diagnosed the patient with adjustment disorder and rule out major depressive disorder. In the month and year specified, the reported diagnosis was persistent mood disorder with anxious distress. The patient was experiencing significant affective impairment which is expected as depression is a recurrent illness. Additionally, at the time, the patient was enduring psychosocial stressors. She was negotiating a job change and consolidating health concerns while two days prior to the first of the disputed sessions she had a relationship break up. The patient was depressed, irritable and anxious, with impaired insight, judgment and thought processing. Effective psychotherapy is a trusted intervention in the treatment for patients with depression and anxiety. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Further a study by Cuijpers and colleagues identified that at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. Thus a treatment course of seven sessions is well within accepted practice standards. Based on the patients history, including past success with therapy, and her psychosocial stressors at the time, the services provided were reasonably expected to improve her situation, and prevent a more serious illness and the need for more intensive treatment. Therefore, the two sessions provided on the dates indicated were safe, appropriate and consistent with good medical care. Thus, the services at issue were medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A thirty year-old male with extensive psoriasis involving the face, neck, chest, back, upper extremities, lower extremities and gluteal crease is requesting authorization for Enbrel.  The patients gastroenterologist affirms that the patients gastrointestinal condition would make it unlikely that he would be able to tolerate oral medications for this psoriasis. The patient is not aware of locally available UVA or UVB treatment.Reviewers Findings:The reviewing physician found that the patient has severe disease and Enbrel is medically appropriate unless it can be demonstrated that UVA or UVB treatment is readily available and would not be excessively burdensome for the patient to pursue.  Since UVA or UVB is not available the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested surgical repair of her left rotator cuff for treatment of her medical condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although surgical repair of rotator cuff tears is supported by the medical literature, it remains unclear in this case whether the patient actually has a rotator cuff tear present.  The MRI of the left shoulder with contrast was noted to reveal no evidence for rotator cuff defect or re-tear.  The clinical note, noted that an MRI arthrogram performed postoperatively showed a re-tear of the rotator cuff tendon, a remnant bone spur and some continued acromioclavicular joint arthrosis.  However, this MRI was not provided for review.  The clinical note stated that the patient had positive OBriens test and positive Jobes test.  However, the patient had full active range of motion and 5/5 strength during external rotation.  This examination does not support a re-tear.  The provider ordered a new MRI with contrast and the patient was to return for re-evaluation after the MRI was completed.  Without evidence of rotator cuff tear via imaging study, the request for left shoulder rotator cuff repair is not supported and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab for treatment of the enrollees systemic sclerosis.Findings: The physician reviewers found that this is a case of systemic sclerosis manifested by skin findings, gastroesophageal reflux disease (GERD) with esophagitis, Raynauds and myopathy. Previous therapy has included methotrexate which was stopped for three weeks due to axillary lymph node, and mycophenolate. However, the patients records do not document treatment or a contraindication to treatment with cyclophosphamide. The current literature demonstrates a possible benefit of rituximab in skin symptoms, but larger, randomized controlled studies have not been performed to confirm the safety and effectiveness of this treatment. Given these findings, the requested rituximab 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: Two physician reviewers are board certified in internal medicine with sub-specialty certifications in allergy and immunology and rheumatology and are actively practicing. One physician reviewer is board certified in neurology with sub-specialty certification in neuromuscular medicine and is actively practicing.  The reviewer 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

The patient has requested authorization and coverage for any or all facial feminization services: grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, each additional 25 cc injectate, or part thereof; genioplasty augmentation; tracheoplasty cervical; otoplasty protruding ear, cervicoplasty; excision excessive skin and subcutaneous tissue other area; reduction forehead contouring only; osteoplasty facial bones reduction. Researchers reported that transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. facial feminization surgery, gender reassignment surgery, or both) are associated with improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement notes, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The Health Plans claim that the patients individual facial features fall within a normal range for a female does not address the masculine impression of the facial features in relation to one another, nor the resulting dysphoria the patient experiences. The medical evidence supports the requested surgeries in this clinical setting. Therefore, all of the following requested facial feminization surgeries are medically necessary for the treatment of this patient: grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, each additional 25 cc injectate, or part thereof; genioplasty augmentation; tracheoplasty cervical; otoplasty protruding ear, cervicoplasty; excision excessive skin and subcutaneous tissue other area; reduction forehead contouring only; osteoplasty facial bones reduction. Final Result: The reviewer determined that all 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 psychiatry with expertise in transgender health 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 42-year-old male enrollee has requested Orthovisc injections for the treatment of his osteoarthritis. Findings:  The physician reviewer found that patients with osteoarthritis of the knee obtain moderate benefit from treatment with viscosupplementation. That stated, not all patients receive the same relief with the therapy; as this patients records demonstrate, he only received mild relief of his symptoms after treatment. For patients who obtain measurable positive pain relief with prior injections it may be medically justifiable to authorize future treatments after a reasonable waiting period. However, based on the records provided this patient has not met these criteria. Furthermore, the concept that viscosupplementation is likely to have a better effect after the microfracture procedure warrants further study, but has not yet been medically proven. There is even less support for the proposed therapy in patients such as this patient who failed to obtain moderate benefit with prior treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of Xeljanz XR 11mg tablets. The Health Plan has denied this request as not medically necessary to treat the patients medical condition.In review of the current literature, it is found that the request for brand name Xeljanz in the treatment of ANCA-associated vasculitis has minimal support for its use in this clinical setting. In one article, the authors reported on a case study reporting successful treatment of polyarteritis nodosum (PAN) with Xeljanz. Overall, there is a paucity of medical literature to support the use of Xeljanz in the treatment of ANCA-associated vasculitis. Therefore, the Xeljanz XR 11mg tablets are not medically necessary for 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 allergy and immunology and internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested mental health residential treatment center services for treatment of the enrollees behavioral health condition. The physician reviewer found that the mental health residential treatment center services were medically necessary for treatment of the patients medical condition. Based on the documentation provided, this patient does meet the American Society for Addiction Medicine (ASAM) adolescent criteria for continued stay in the residential treatment level of care. In this case, the patient remained at moderate risk of harm and needed a stable living environment for safety. Her home environment presents moderate to severe interference with recovery. She exhibits evidence of moderate impairment in her social functioning and she has a history of prolonged use and poor response to stress. In addition, the patient requires moderate to intensive motivating in a 24-hour structured environment to promote or sustain progress. She is unable to control use and avoid serious impairment without a 24-hour structured program as she is unable to overcome environmental triggers or cravings and has insufficient supervision at home. Finally, her home environment poses a risk to her recovery such that she requires residential treatment center services support. In sum, the services in dispute were medically necessary and reasonably expected to improve the patients condition and prevent a more serious episode of illness. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female enrollee has requested authorization and coverage for enteral formula and supplies for treatment of the enrollee, who has been diagnosed with failure to thrive. Findings:  The physician reviewer found that feeding disorders are relatively common in children, occurring in up to 25% of all children, and up to 80% of developmentally disabled children.  The etiology of feeding disorders is multifactorial, involving medical, behavioral, and environmental factors. Feeding disorders may manifest as inadequate fluid intake, food refusal, difficulty swallowing, an inability to feed oneself, choking or gagging, food selectivity, and inappropriate behaviors at meal times. The impact of significant feeding disorders can be substantial, affecting growth and development, nutritional status, and cognitive development.  In this patients case, all attempts to discontinue the enteral formula have resulted in weight loss, despite addition of appetite stimulants. Her failure to maintain weight upon the most recent discontinuation of gastrostomy tube feedings demonstrates an inability to consume enough calories by mouth to promote growth and development.  All told, the requested enteral formula and supplies are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested digital breast tomosynthesis (3D mammogram) for treatment of her breast cancer screening.  Findings:  The physician reviewer found that breast digital tomosynthesis is a relatively new technique in breast imaging with recent FDA approval. The technique shows promise in the early detection of breast cancer, particularly Grade 1 tumors. In multiple studies, the early data show no statistically significant difference in cancer detection rate. The American College of Radiology (ACR) guideline does not list tomosynthesis as part of the mammographic screening technique. Therefore, the requested digital tomosynthesis service is not medically necessary for treatment of this enrollee's medical condition.