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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with obesity. The patient underwent laparoscopic gastric band placement with removal. The patient was subsequently diagnosed with breast cancer and underwent mastectomies with placement of tissue expanders. The patient reported that she gained weight due to chemotherapy treatment and endorsed pain caused by the tissue expanders. The patients provider requested the patient undergo laparoscopic sleeve gastrectomy for weight loss prior to undergoing breast reconstruction with flap surgery. She attended a bariatric support group. The patient also underwent a psycho-social and behavioral evaluation and was reported to be a good candidate for bariatric surgery. At issue in this case is whether a bariatric consultation is medically necessary for the evaluation of this patients medical condition. As noted by the American Society for Metabolic and Bariatric Surgery (ASMBS), patients with a BMI of 35 or greater with one or more severe obesity-related co-morbidity, including considerably impaired quality of life are considered potential candidates for bariatric procedures. The ASMBS support that disqualification from other surgeries as a result of type II obesity, as defined by a BMI of 35-39.9, is considered an indication for bariatric surgery. Overall, the evidence regarding reoperative surgery for failed weight loss and weight regain demonstrates improved weight loss and co-morbidity reduction after re-intervention . The patient reported pain related to her breast tissue expanders and breast reconstruction surgery was postponed until weight loss is achieved. Further, the patients provider recommended laparoscopic sleeve gastrectomy for weight loss prior to undergoing breast reconstruction. In addition, the patient demonstrated motivation for weight loss by attending bariatric support groups and was reported to be a good candidate for bariatric surgery by a psychological evaluation. Therefore, a bariatric consultation is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service 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 family practice and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Otezla Starter Pack followed by 30 mg twice a day.Findings: Otezla (apremilast) is a phosphodiesterase 4 inhibitor, which decreases PDE4 activity, which in turn reduces the inflammatory process thought to be associated with psoriasis. Researchers noted that Otezla is also indicated for psoriatic arthritis. According to guidelines of care for the management of psoriasis, `Overall, apremilast as monotherapy is beneficial to treat psoriasis and psoriatic arthritis. These benefits include oral administration and the lack of a requirement for laboratory monitoring. For patients who would prefer to avoid frequent injections as well as laboratory monitoring and are willing to accept a slower onset of skin clearance and lower likelihood of clearing, apremilast is an appropriate choice.`In this case, the patient has been having psoriasis vulgaris symptoms for several years. On their initial visit, the patient reported the use of numerous topical steroids of varying strengths with mild improvement. They were found to have psoriasis affecting about 10% of the body surface area. They also complained of joint pain and had needle phobia. Medications included Concerta and Zyrtec. They were started on Otezla, which did improve the skin disease at the three-month follow-up. Additionally, the patient has a needle phobia which makes most biologics not appropriate. Alternative treatments such as acitretin, methotrexate and cyclosporine all require frequent lab monitoring and have more potential for side effects. Otezla is a reasonable choice for the patient given it will require fewer needle sticks in the long-term for lab monitoring. Under these circumstances, the requested medication, Otezla Starter Pack followed by 30 mg twice a day, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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

Physician 1: The patient is a 37-year-old male with degenerative disc disease at L5-S1. The patient is status post discectomy. His provider is recommending a single level disc replacement utilizing the Charite artificial disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental, as there is no long-term data demonstrating long-term safety and efficacy of the procedure. Moreover, the patient does not meet FDA criteria for lumbar disc replacement as he has had a previous discectomy at L5-S1 and has leg numbness and pain. Previous surgery such as this is considered a contraindication to artificial disc replacement. Based upon the information set forth above, I have determined the requested procedure 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.Physician 2: The patient is a 37-year-old male with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patients provider indicates the patient has previously undergone discectomy at L5-S1. The Health Plan has denied authorization for the requested procedure indicating the efficacy of artificial disc replacement has not been established.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure 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.Physician 3: The patient is a 37-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter placement of intravascular stent(s), intracranial, including balloon angioplasty. The records reviewed document that this patient has a history of idiopathic intracranial hypertension. The intracranial hypertension was found to be due to stenosis of the venous sinus with a large arachnoid granulation. The provider has recommended stenting of the venous sinus. Intracranial hypertension has been found to be related to venous sinus stenosis and stenting has been successful for the treatment of a majority of patients in this clinical setting. Given this support, the requested transcatheter placement of intravascular stent(s), intracranial, including balloon angioplasty is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 proton beam therapy. Currently, there is inadequate clinical data supporting that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, the authors observed that IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities. Yu and colleagues found that there was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, but this difference disappeared by one year, and there were no other significant differences in toxicity between the two techniques. Further, the American Society of Radiation Oncology (ASTRO) stated that, the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO. This patients receipt of high-dose rate brachytherapy does not necessitate the use of proton therapy. The patients prostate would not undergo reirradiation, as the pelvis requires treatment which did not undergo radiation from the brachytherapy procedure. Treatment of the pelvis after brachytherapy is routinely performed with photons with standard IMRT technique. For these reasons, the requested proton beam therapy is not medically necessary for treatment of this patient. 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 radiation oncology 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 applied behavioral analysis (ABA) direct services for treatment of the enrollees autism spectrum disorder.  Findings: The physician reviewer found that ABA therapy is medically indicated for children with autism spectrum disorders. In this case, the patient has received a high level of ABA services. However, he has not yet met his behavioral goals and he continues to have a high level of maladaptive behaviors. There is a lack of evidence provided that shows he has made enough progress to allow for a reduction in ABA hours. In addition, the patients maladaptive behaviors including aggression, non-compliance and vocal protest require a high level of ABA services. The ABA providers recommendation of 40 hours per week of ABA therapy and supervision are medically necessary in this clinical setting.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 developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that no computed tomography (CT) scan was reportedly performed in this patient. The records do not demonstrate that the patient has been medically treated prior to consideration for surgery.  All told, the medical records suggest that the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 2b. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret for eight weeks. The guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 weekly individual therapy services in 50-minute format. The American Psychiatric Association (APA) practice guidelines for the treatment of major depressive disorder recommend medication management by a psychiatrist along with weekly individual or group psychotherapy when possible. In this case, the patient has a history of major depressive disorder. Her medication management is being handled by her primary care physician, and the patient declined medication trials recommended by her psychiatrist. The patient was being seen by an outside provider for weekly individual therapy services without psychopharmacologic medication management. In this clinical setting, weekly individual psychotherapy services in conjunction with ongoing psychopharmacologic management by a psychiatrist is standard of care. While the patient has refused psychopharmacologic management and is on psychotherapy alone, the requested services are medically indicated. Therefore, weekly individual therapy services in 50-minute format are medically necessary for the 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 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 Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that pursuant to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined 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

A 60-year-old female enrollee has requested for MRIs of the abdomen and pelvis for evaluation of her pelvic pain. Findings:  The physician reviewer found that a pelvic MRI was also felt not to be medically necessary based on InterQual criteria as there were no pelvic masses or suspicion of cancer.  However, InterQual guidelines do recommend pelvic MRI for the diagnosis of endometriosis and this would apply to the case of this patient who had had a history of endometriosis for which she underwent a hysterectomy. Although uncommon, it is possible for endometriosis to recur particularly in patients who are on estrogen replacement as is the case with this patient.
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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by a researcher, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Researchers also reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   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 54-year-old female enrollee has requested authorization and coverage for a referral to a neurologist for treatment of the enrollees vague intermittent abnormal sensation in the left heel. Findings:  The physician reviewer found that the submitted medical documentation demonstrates the medical necessity of the requested services.  This patient presented with initial left foot symptoms thought to be due to local irritation.  She then had tingling of the left face, arm and leg, clumsiness of gait and hand, and difficulty with swallowing.  Neurologic examination was normal, and examination by her primary care physician was normal.  The differential diagnosis of unilateral sensory disturbance, clumsiness, and swallow difficulty is wide, including conditions such as multiple sclerosis, vasculitis, neurodegenerative disorders, or somatization.  The medical literature shows that neurology training of primary care physicians is scant, often with no specific education beyond what is conveyed in medical school.  As a result, specialty specific physical examination and diagnostic assessment is likely to be more accurate.  All told, the requested referral to a neurologist is medically indicated for the treatment of this patient.