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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx Uveal Melanoma testing. Findings:  Three physician reviewers found Local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95% of cases, yet up to 50% of patients remain at risk for metastatic disease. Gene expression profiling has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, gene expression profiling classifies tumors as having Class 1, consistent with a low risk or Class 2, which suggests a high risk for metastatic. Moreover, this profile test is considered within the standard of care and is recommended by the National Comprehensive Center Network (NCCN) guidelines. Accordingly, the DecisionDx Uveal Melanoma testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.For these reasons, the DecisionDx Uveal Melanoma testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx Uveal Melanoma testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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 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 66-year-old male with type 2 diabetes mellitus (DM2). His blood glucose levels had previously been under good control on Actos, metformin and glipizide as evidenced by a hemoglobin A1c of 6.0%, excellent fasting blood glucose and occasional postprandial elevations of blood glucose according to his endocrinologist. The patient has macrovascular and mild microvascular disease and he is obese. He has reportedly been unable to lose weight with his current diet and exercise. In July 2006 his endocrinologist started the patient on Byetta for greater blood glucose control and to aid in his weight loss efforts and glipizide was discontinued. The patients primary care provider stated in his letter of October 2006 that the patient had lost close to 10 pounds and his provider wished to continue Byetta, presumably for further weight loss. The patients request for authorization of Byetta was denied by the Health Plan citing a lack of medical necessity. The patient appears to have had excellent control of his DM2 while taking Actos, metformin and a small amount of glipizide. Excellent control is defined by the American Diabetes Association as a hemoglobin A1c of less than 7% and by the American College of Endocrinology as a hemoglobin A1c of less than 6.5%. The patients hemoglobin A1c was 6.0% prior to starting Byetta. The Health Plan will cover Byetta for those patients not in good diabetic control despite compliance with their medication regime. Good control is defined by the Health Plan as a hemoglobin A1c of less than 6.5%, which is consistent with the recommendations of the learned medical societies. Byetta is not a weight loss medication and it is unlikely that the very small dosage of glipizide that the patient was prescribed contributed significantly to his inability to lose weight. Based upon the information set forth above, I have determined the requested medication is 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: An enrollee has requested authorization and coverage for an abdominoplasty for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has a history of chronic abdominal pain/discomfort.  In addition, the patient has a questionable umbilical hernia and a rectus diastasis.  The patients pain has been attributed to the rectus diastasis.  Conservative management attempted by the patient includes binder clothes.  There is some indication that muscle plication may affect intractable lower back pain.  However, the authors noted that nonoperative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patients case, the records do not document sufficient work-up of the pain, and conservative management has not been exhausted.  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 plastic 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested esophagogastroduodenoscopy (EGD) with Botox injection for treatment of her medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The records do not clearly demonstrate that the patient has gastroparesis.  Secondly, controlled data have shown that Botox into the pylorus is no better than placebo for gastroparesis. This includes no benefit for symptom reduction or improvement in gastric emptying.  All told, the requested EGD with Botox injection is not likely to be more effective than other treatment options. Final Result: Three reviewers determined that the requested services are 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 59-year-old female enrollee has requested a continuous passive motion machine for the treatment of the enrollee, who is status post total knee replacement. Findings:  The physician reviewer found that the results published since 2000 have demonstrated with reasonable medical probability that a combination of use of a continuous passive motion machine with physical therapy is more beneficial than either use of continuous passive motion machine or physical therapy when administered alone. The literature published prior to 2000 was undertaken when a hospitalization of 10 days or more was the general length of stay. As such, these patients often had 10 to 14 days of use of continuous passive motion machine prior to discharge, and the benefits of prolonged courses of use of this equipment in addition to that were not demonstrated. However, given the very brief lengths of stay for joint replacement currently, a relatively short course of home use of the continuous passive motion machine has become the standard treatment. Given the length of this patients hospital stay and support from the literature demonstrating improved outcome of physical therapy with use of continuous passive motion machine versus either physical therapy or use of a continuous passive motion machine alone, it was medically appropriate and indicated that this patient have home use of this equipment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested accelerated partial breast irradiation (APBI) brachytherapy for treatment of her breast cancer. Findings:  Two physician reviewers found that in the medical literature, younger age has been documented to be a dominant adverse prognostic factor for in-breast local recurrence. According to the collective experience from modern APBI series, patients older than 50 years of age can be treated successfully with a 50 Gy equivalent dose. However, conflicting results have been reported for patients aged 41 to 50 years. In one APBI trial, the age of patients who were 40 years or younger was found to be the most important negative prognostic factor for local recurrence (Polgar, et al). In addition, patients younger than 40 years were excluded from successful studies. The American Society for Radiation Oncology (ASTRO) guidelines deem patients younger than 50 years of age to be poor candidate for treatment with APBI. Therefore, further prospective studies are needed to support the use of APBI for women between the ages of 41 and 50 years. Consistent with these findings, the requested APBI brachytherapy is not likely to provide this patient with a superior health outcome when compared with standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested services of an anesthesiologist during a colonoscopy for evaluation of his colonic polyps. The physician reviewer found that the use of monitored anesthesia care services during the colonoscopy was not medically necessary. Per the peer-reviewed medical literature, an alternative to monitored anesthesia care is the administration of propofol by a specially trained nurse or endoscopy assistant, working under the direction of an endoscopist. Given its pharmacologic properties, propofol has been rapidly adopted for gastrointestinal endoscopy for complex procedures and more recently for routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. The use of monitored anesthesia care may be considered necessary for gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures where there is documentation of specific risk factors for significant medical conditions are present. Such increased risks for complications include severe comorbidity, morbid obesity, documented sleep apnea, history of anticipated intolerance to standard sedatives, patients younger than 18 years or 70 years or older, patients with increased risk for airway obstruction due to anatomic variation, and prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation. As the patient does not meet any of the criteria, the use of monitored anesthesia during the patients colonoscopy was not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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: Overturned

The patient has been diagnosed with bilateral knee osteoarthritis. The records noted that the patient was status post posterior medial partial meniscectomy. Per the records, she was one-week status post irrigation and debridement for septic arthritis. The patient reported bilateral knee pain. Physical examination findings included right knee medial joint line tenderness. The patient has been treated with physical therapy, Pennsaid topical cream, and meloxicam. The patient reported that a previous Synvisc One injection provided pain relief for approximately two years. The patient has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. In this case, the patient has had prior viscosupplementation with Synvisc One injections with good results. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees 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 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

A 54-year-old female enrollee has requested an MRI of the left knee for an evaluation of her knee injury. Findings:  The physician reviewer found that without a full assessment of her knee by a qualified specialist, it cannot be determined whether or not an MRI study is needed. The x-ray evaluation was essentially normal and there is no history of locking of the knee joint. The patient requires an examination by an orthopedic specialist who can determine the next appropriate diagnostic or treatment intervention.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for emergency work up for liver transplant and placement on liver transplant list for treatment of her acute liver failure.  Findings:  The physician reviewer found that most transplant centers follow an integrated approach designated to minimize the risk of alcohol recidivism, as it is currently the primary factor that jeopardizes transplant outcomes in patients with a history of alcohol consumption. To this end, thorough psychological and chemical dependency assessments are included in the transplant evaluation process. Lucey and colleagues note that a number of criteria are considered to predict abstinence after transplantation, including medical, surgical, and psychiatric assessment. Anantharaju and Van Thiel indicate that due to the shortage of donor organs, orthotopic liver transplantation (OLT) for alcoholic liver disease patients, remains controversial out of concerns that patients may resume drinking, thereby harming the transplanted organ. Some transplant centers have used contingency contracting as a method to improve long-term abstinence, but oftentimes, patients with a history of alcohol use are enrolled in an alcohol treatment program and may be required to submit to random alcohol testing while awaiting transplantation. Some researchers consider an abstinence period of six months prior to OLT a predictor of long-term abstinence, suggesting that patients who are abstinent for less than six months have a greater relapse rate. At present, the six-month abstinence rule is followed by most of the transplant centers in the United States, and patients are required to go through intensive alcohol rehabilitation prior to being listed. According to the submitted medical records, the patient has not been abstinent from alcohol for six months. Further, there is no documentation that she has participated in an alcohol rehabilitation program since last consuming alcohol.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The parent of a transgender male enrollee has requested authorization and coverage for the medication testosterone cypionate for treatment of the enrollees gender dysphoria.Findings:  The physician reviewer found that the documentation submitted supports the medical necessity of the requested medication in this clinical setting. Hormonal treatment with gender affirming hormones is accepted as standard of care for both adolescents and adults diagnosed with gender incongruence. The records document that this patient has undergone a complete medical and psychological evaluation and continues to participate in therapy. He is a good candidate for medical management with hormones. The records indicate that he has the support of his parents and therapists. Similar to other adolescents with gender dysphoria, his medical history includes anxiety, depression and history of self harming behaviors. With treatment, his symptoms have improved. This patients positive emotional changes are well supported in the medical literature in that medical treatment improves the psychological well being in those adolescents who are diagnosed with gender dysphoria. Therefore, testosterone cypionate is medically necessary for the treatment of this patients gender dysphoria. 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 endocrinology and metabolism and expertise in transgender 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan tablets. Findings: A study concluded that rifaximin seemed effective and safe for the treatment of SIBO. Another study found that rifaximin, a nonsytemic antibiotic, was effective against SIBO and well tolerated. Other research noted the rifaximin was the most commonly prescribed antibiotic regimen for SIBO therapy and that treatment with rifaximin may be highly effective in providing symptom relief from the effects of SIBO. In this case, the patient has tested positive for SIBO and has persistent associated symptoms. Therefore, Xifaxan tablets are medically necessary for the treatment of 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: Upheld

A 58-year-old male enrollee requested Lyrica 75 mg for medical treatment of his peripheral neuropathy.  Findings:  The physician reviewer found that the requested medication is not supported as medically necessary for this patient given the lack of documentation that he has failed other therapeutic options or that the patient is a non-candidate for such therapy. The available medical records describe a trial of gabapentin without benefit at 800 mg three times per day but do not demonstrate failure of duloxetine. Further, the records do not demonstrate ongoing risk or a potential of risk related to duloxetine use. Although the available medical records do support that the patient failed treatment with gabapentin, it does not support that duloxetine was tried and failed or that there was contraindication to duloxetine. Thus, the requested Lyrica 75 mg is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cardiac positron emission tomography (PET) scan. The records document that this patient has a history of a history of hyperlipidemia and diabetes. The patient underwent evaluation with cardiac PET scan. As noted in the medical literature, cardiac PET imaging can assess myocardial viability and blood flow to assess cardiac ischemia when SPECT imaging is inconclusive or contraindicated. However, prospective randomized clinical trials have not demonstrated the superiority of PET compared with SPECT imaging in the assessment of patients for possible coronary artery disease risk as in this patients clinical setting. The available documentation does not report that SPECT imaging was contraindicated or inconclusive. The current guidelines do not support the use of cardiac PET imaging in this role when other functional testing, such as SPECT, can be utilized. All told, the cardiac PET scan 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 cardiac PET scan 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 reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease 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.