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

A 70-year-old female enrollee has requested for skilled nursing facility level of care with physical therapy and occupational therapy for treatment of her Guillain-Barre syndrome. Findings:  The physician reviewer found that Guillain-Barre syndrome (GBS) has a generally favorable natural course and relatively good prognosis. There are standard treatment options that have demonstrated to be effective treatments for this condition (van Doorn, et al.). Despite the generally good prognosis and available therapeutic options, some patients continue to have significant functional impairments at six months or longer following the onset of symptoms. To date, highly intensive rehabilitation services have not been proven to effectuate better long-term functional outcomes in this setting (Khan, et al.). Further inpatient rehabilitation and skilled nursing facility level care including physical therapy and occupational therapy is not medically necessary. Rehabilitation services can be provided in the community setting. Further inpatient care would be custodial in nature based on the available records, and therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male has requested Lyrica for treatment of severe pain.  Findings:  The physician reviewer found that pain management practitioners have found Lyrica very effective especially in managing chronic neuropathic pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three dimensional (3D) digital breast tomosynthesis for evaluation of her risk for breast cancer. Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of 3D digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: 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: All three reviewers are board certified in diagnostic radiology and are 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: Medical Necessity
Decision: Overturned

A 77-year-old male enrollee requested a knee brace for medical treatment of his knee pain.  Findings:  The physician reviewer found that there is sufficient support for the requested knee brace in this clinical setting.  This patient has documented malalignment.  Given this patients multiple comorbidities and age, the requested knee brace is likely to be beneficial.  Lorbach and colleagues noted that several studies have demonstrated a reduction in pain with the use of unloader braces.  The authors reported that while orthotics such as a medial unloader braces are not likely to alter the long-term effects of osteoarthritis, they are likely to result in short-term benefit.  The literature review by Maleki and colleagues supports the use of the medial unloader valgus brace as a conservative treatment for medial knee osteoarthritis.  All told, the requested knee brace is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested for a colonoscopy for evaluation of her medical condition. Findings:  The physician reviewer found that there is no evidence in the documentation provided for review that this patient has any symptoms of abdominal pain or gastrointestinal bleeding. The information in the peer-reviewed medical literature does not support the use of screening colonoscopy in low risk patients prior to the age of 50. Although this patient has a family history of colon cancer, the family history does not involve a first degree relative and she has no other signs or symptoms that would place her in a moderate or high risk category for developing colon cancer. As such, the requested procedure is not medically necessary and the Health Plans denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant Health gene test (CPT 81479). Langerhans cell histiocytosis is characterized by single or multiple osteolytic bone lesions or skin rashes demonstrating infiltration with histiocytes with bean-shaped nuclei on biopsy, with or without histiocytic infiltration of extraskeletal tissues. As part of the work-up, BRAF testing is indicated and can be performed without an entire molecular panel. This patients records document a diagnosis of Langerhans cell histiocytosis, but there is no report of BRAF testing prior to the Guardant360 assay. Although BRAF mutation is recommended, there is a lack of support for additional molecular testing to help guide treatment decisions making. Thus, the Guardant Health gene test (CPT 81479) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Guardant Health gene test (CPT 81479) 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 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 subspecialty 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: Medical Necessity
Decision: Overturned

This patient is a 28-year-old woman with long-standing lumbar pain. She had surgery at a young age. She has spondylosis and probable arthritis secondary to surgical fusion at an early age. The patient reports methylprednisolone and Celebrex 200mg once daily has provided significant pain relief. She has requested authorization and coverage for Celebrex, which has been denied by the Health Plan. The submitted clinical information demonstrates the patient has taken Celebrex with documented clinical benefit. Celebrex is an anti-inflammatory and is indicated for patients with back pain, lumbar stress, lumbar arthritis, and other conditions such as spondylosis and spondylolisthesis when inflammation has developed. The patient has benefited from Celebrex in the past and is likely to experience continued benefit. As such, its continued use is medically appropriate in this clinical setting and should be authorized. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found that there is a lack of support for the superior efficacy of the genetic testing except for the BRCA1 and BRCA2 genetic testing portion of the services at issue. According to National Comprehensive Cancer Network guidelines, a patient with breast cancer should be BRCA tested only under certain circumstances. The guidelines would recommend BRCA testing for this patient if she has a relative (first-second, or third degree relative) with ovarian cancer. The patient reported family members who have been diagnosed with breast and ovarian cancers. However, the genetic testing at issue involved a multigene panel, which included BRCA as well as other multiple gene abnormalities. Though these other gene mutations are of interest and are being studied, they have as yet not been found to be significant enough to be the basis for any clinical decisions for the patient or their family members. Such testing is not included in the guidelines from the major organizations. Therefore, the BRCA1 and BRCA2 portion of the multigene panel  received would likely have been more beneficial for the evaluation this patient, but the other portions of the multigene panel would not likely have been more effective. Final Result: 2 of 3 reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three reviewers 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 are 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 a 12-year-old enrollee has requested Mekinist for treatment of the enrollees ependymoma.  Findings: The physician reviewer found that patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. This may be particularly relevant for very rare cancers where even phase II studies may be not be effectively conducted due to poor accrual. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients was conducted by Von Hoff and colleagues. The authors reported progression-free survival on a regimen selected by molecular profiling was compared to progression free survival rate on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This patients tumor had mutational profiling done which revealed a BRAF mutation, V600E that has been described in melanoma, colon cancer, lung cancer, hairy cell leukemias, among others. Mekinist is an inhibitor of MEK kinases approved for use in metastatic melanoma with BRAF mutation (Wright and McCormack). The MEK kinases are within the same pathway as RAS and BRAF (Pylayeva-Gupta, et al). Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling such as this patients tumor. A phase I trial showed that Mekinist was tolerated at 2 mg twice daily with responses in patients with diverse cancers (Infante, et al). Given this support, the requested Mekinist is medically necessary for treatment of this patients ependymoma.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 oncology and hematology 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 12-year-old male with a history of developmental delays including significant speech delay. There is also a reported history of otitis media with effusion. The patient has been receiving speech therapy. Periodic reevaluations have reflected some improvement in speech. A request has been made for additional speech therapy services. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. While the submitted information indicates the patient has been diagnosed with Aspergers syndrome and otitis media with effusion, no supporting documentation has been provided. Formal developmental testing results are not available. In addition, the patients hearing is reported to be normal. Thus, there is insufficient evidence that speech therapy is medically warranted. As such, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections. 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 routine 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 patient has a history of good response to viscosupplementation with Synvisc injections of both knees. Furthermore, treatment with oral and topical non-steroidal anti-inflammatory drugs (NSAIDs) has not provided substantial relief of the patients symptoms. The patients remaining treatment options include total knee arthroplasty. The provider has recommended repeat viscosupplementation with Synvisc injections of both knees. On review of the current medical literature, the patient is a suitable candidate for repeat viscosupplementation. For these reasons, the requested Synvisc injections are 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: Upheld

The patient is a 32-year-old female who has been experiencing constipation, cramping and bloating. In November 2004, the patients physician recommended the patient use Zelnorm for irritable bowel syndrome (IBS). The Health Plan has denied authorization and coverage for Zelnorm indicating the submitted documentation does not support a diagnosis of IBS.Upon review of the information provided, it does not appear the patient has undergone a complete gastrointestinal workup. The submitted information does not demonstrate the etiology of the patients abdominal symptoms. A full evaluation by a gastroenterologist is needed to establish a diagnosis and to determine optimal therapy. Thus, use of Zelnorm is not medically indicated at this time. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

SummaryThe patient is a 54-year-old female with stage IV breast cancer.  She is requesting authorization for treatment with Sutent. The Health Plan denied her request citing the experimental nature of the therapy in this clinical setting.  The three physicians reviewing the case all found that the Health Plan denial should be upheld.Analysis and FindingsClinical Facts:  The patient has a history of advanced breast cancer initially diagnosed in 1993. As per the record, her treatment has included the following chemotherapeutic regimens: FAC, HD SCT/etoposide, tamoxifen, Femara, Aromasin, Herceptin, Taxotere, lapatinib, Navelbine/Herceptin, Herceptin/Gemzar/Xeloda, Alimata/Herceptin, Doxil, Gemzar/Oxaliplatin and several clinical trials. Complicating the clinical picture are diagnoses of brain metastases and hypertension and treatment with Temodar.Reviewers Findings:The three reviewers indicated that although Sutent is an up and coming drug in the management of several types of malignancies including breast, it remains experimental.  And there is only one small phase II study that may show benefit in patients with a heavily pre-treated history. The manufacturer reports that seizures have been observed in subjects with radiological evidence of brain metastases. In fact, all of the angiogenesis inhibitors are known to carry an increased risk of tumor hemorrhage and this complication is potentially devastating in the context of brain metastases. Additionally, liver function is often adversely affected. Any preliminary data that may support the efficacy of this therapy is not sufficient to offset the lack of data supporting the safety of the proposed treatment with Sutent.  Therefore, the three reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers, especially in women with dense breast tissue.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: 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: All three reviewers are board certified in diagnostic radiology and are 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. Norco is an opiate pain medication which is usually prescribed for postoperative pain control, chronic malignant and non-malignant pain and cancer pain. This medication is highly addictive. This patient has had multiple diagnostic studies which were negative for abdominal pathology. Opiates also cause constipation which can result in abdominal pain and discomfort. At this point, it is medically appropriate that the patient be weaned off opiates and be placed on alternative pain medications until her diagnosis is clear. The records indicate that she is awaiting a third opinion consultation with a provider who specializes in gastroenterology. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norco is not medically necessary for the 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 anesthesiology 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 patient has a medical history of gender dysphoria. A letter from the patients representative dated 12/7/18 states that the patient has been taking cross gender hormone therapy since July 2018. The letter reported that the patients symptoms of gender dysphoria have manifested with persistent anxiety, depression, agoraphobia, and overall distress. She has met with her medical provider to discuss laser facial hair removal, and the provider determined that facial laser hair removal is appropriate to treat her gender dysphoria. The letter states that the patients facial hair severely limits her ability to be perceived as female and thus negates her gender identity. Being constantly mis-gendered due to the presence of facial hair exacerbates her symptoms of gender dysphoria. At issue in this case is whether facial laser hair removal is medically necessary for treatment of the patients medical condition. Feminizing hormones can reduce the density and quality of facial and body hair. The World Professional Association for Transgender Health (WPATH) cites reviews at 6-12 month follow-up for assessment of patient response. In this case, the patient was on hormone therapy for three months and no assessment was made during the office visits of any changes in facial or body hair. The providers progress notes fail to document any discussion with the patient about expectations of hormone therapy on hair growth, evaluation of any impact of initiating cross gender hormones, or justification for laser hair removal. Overall, the records do not support that the patient has undergone an adequate trial of hormone therapy and assessment of its impact on facial and body hair. Therefore, the requested laser facial hair removal is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.