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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation supports the medical necessity of the requested medication.  The patients weight for height ratio is normal, and other causes of short stature have been ruled out. This patient has not undergone provocative growth hormone (GH) testing. However, the patient meets criteria for a trial of GH therapy for treatment of idiopathic short stature. The U.S. Food and Drug Administration has approved GH therapy for children with short stature who are predicted to reach an adult height of less than 63 inches in males and less than 59 inches in females. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature; who pass GH stimulation tests, but who meet several of the following criteria; height is more than 2.25 standard deviations below the mean for age, or more than two standard deviations below the mid-parental height percentile; or growth velocity of less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factors-1 and/or insulin-like growth factor-binding protein 3; and/or other clinical features suggestive of GH deficiency. This patient meets a significant portion of the above criteria, and GH therapy for treatment of idiopathic short stature is medically necessary until epiphyseal fusion. Therefore, Genotropin is 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 19-year-old female enrollee has requested for vertebral axial decompression therapy for treatment of her lumbar pain and disc herniation at L4-L5.   Findings:  Three physician reviewers found that decompressive spinal therapy is no more effective in improving pain and decreasing disability than other standard treatments of lower back pain with or without sciatica. Although there may be anecdotal reports of decompressive therapy providing relief, this is not supported by the scientific studies available. It is also not clear as to whether the patient has tried all other standard treatments (e.g., physical therapy or other non-surgical treatments).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that there is a lack of peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques, especially in a patient without a personal or family history of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Therefore, 3D breast tomosynthesis was not likely to be more beneficial than other modalities. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  Per the guidelines, treatment-naive, genotype 1a patients should be treated with Harvoni or Viekira Pak/ribavirin. These guideline recommendations are based on multiple randomized clinical trials, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a pre-existing condition.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Qualifications/Credentials: The physician 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyrem 500 mg/mL oral solution. Xyrem is indicated to treat narcolepsy type 1 or 2 when a patient fails or unable to tolerate wake promoting medications. Type 2 narcolepsy is associated with cataplexy. Diagnosis of narcolepsy requires a sleep study with MSLT showing sleep latency below eight minutes associated with two sleep onset REM sleep. This patients sleep study and MSLT do not meet these criteria. The MSLT demonstrated severe idiopathic hypersomnia with no SOREM with a mean sleep latency of 6.3 minutes over five naps. Xyrem is not U.S. Food and Drug Administration (FDA) approved or recommended for patients with idiopathic hypersomnia. For these reasons, the requested Xyrem 500 mg/mL oral solution is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in sleep 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Zoll Life Vest wearable cardioverter defibrillator for treatment of the enrollees ST-elevation myocardial infarction (STEMI) status post percutaneous coronary intervention (PCI) to proximal mid left anterior descending (LAD) artery with one drug eluting stent.  Findings:  The physician reviewers found that there is potential for recovery of LV function over time after revascularization and with medical therapy. There was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least three months have elapsed where continued LVEF of 35% or less is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve health outcomes. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. Final Result: All three reviewers determined that the device at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

A 23-year-old female has requested the RT300-SLSA FES integrated cycle system for treatment of her tetraplegia.  Findings:  Two physician reviewers found that the patient has C5 tetraplegia as a result of the onset of transverse myelitis.  Per the submitted documentation, the patient has utilized the requested device, with favorable results.  In this clinical setting, the requested device is likely to be superior over other available treatment options.  Functional electrical stimulation (FES) cycle ergometry has been shown to have positive physiological effects on spinal cord patients which translate into reduced long-term complications.  Multiple studies have shown that FES ergometry can increase muscle volume, improve venous return, and improve cardiac output and endurance with improved oxygen uptake. Some studies also report an increase in bone mineral density.  The pre-morbid functional and fitness level of this patient make her an ideal candidate for requested device.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a series of Ocrevus intravenous (IV) infusions. The U.S. Food and Drug Administration (FDA) approves the use of ocrelizumab (brand name Ocrevus) for the treatment of patients with relapsing or primary progressive forms of multiple sclerosis. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis include offering DMTs to patients with relapsing forms of MS with recent clinical relapses or MRI activity. Hauser and colleagues note that in two phase III trials among patients with relapsing multiple sclerosis, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. McCool and colleagues note that the results of a systemic literature search suggested that ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs across all endpoints analyzed, and a similar safety profile, indicating that it offers a valuable package for the treatment of patients with relapsing multiple sclerosis. In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis, presenting with several relapses and active lesions on MRI. In this clinical setting, given that treatment with DMT is indicated and as current medical literature shows ocrelizumab has an efficacy superior to or comparable with all other currently approved DMTs, the requested service is medically indicated. Therefore, a series of Ocrevus IV infusions is 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 neurology 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 32-year-old male enrollee has requested aspirin desensitization treatment for the treatment of his chronic sinusitis. Findings:  The physician reviewer found that the usefulness of aspirin desensitization treatment in this condition has been well-documented to reduce and/or eliminate anaphylaxis with the use of NSAIDs, significantly improve asthma and to reduce the re-growth of polyps and the need for recurrent surgery. This is well-documented in peer-reviewed published studies. Aspirin desensitization can be performed by a trained allergist/immunologist, and this is medically appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested laparoscopic banding bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has failed dietary efforts in the past, including supervised attempts with her primary care physician.  She has also tried phentermine.  The patient has clinically severe obesity that has failed conservative efforts. She has completed a thorough multidisciplinary evaluation that did not reveal any metabolic, dietary, behavioral or medical barriers to surgery.  This patient meets the National Institutes of Health Consensus Guidelines for bariatric surgery.  In this patients case, the requested laparoscopic banding bariatric surgery is medically indicated for her treatment.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a fifteen-year-old male enrollee has requested for Nutropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that according to the predictive tables of the Greulich and Pyle Hand Atlas, the patients predicted adult height would be in the range of 67 inches. The patient appears to have constitutionally delayed puberty and should exceed the adult height FDA guideline from July 2003 for growth hormone therapy for idiopathic short stature.  He would thus be judged not to require growth hormone therapy, especially if his IGF-1 level has risen as expected with pubertal development.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for knee replacement surgery for treatment of the enrollees bilateral knee pain with diagnosis of degenerative joint disease. Findings:  The physician reviewer found that as noted in the medical literature, total knee arthroplasties in obese patients six months after total joint replacement revealed excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity is not a deterrent to total knee arthroplasty to relieve refractory symptoms. One study referenced 13,673 total knee arthroplasties and found that the improvements in patient reported outcomes were similar without regard for BMI. Final Result: The reviewer determined that the requested surgery 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Paxil and individual psychotherapy for treatment of her depression.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines note that, to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. Nutt noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. All told, this patient would likely benefit further from continued psychotherapy. Bi-weekly psychotherapy is appropriate to treat the patients condition and consistent with standards of good medical practice. In addition, the records indicate the patient has tried and failed specific medication alternatives. Thus, Paxil is appropriate to treat this patients condition, and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested for a CT scan for bone density study for evaluation of his bone density. Findings:  The physician reviewer found that according to the appropriateness criteria of the American College of Radiology, DEXA is the examination of choice to evaluate for osteoporosis. CT scan for bone density study is only indicated if DEXA scan is not available or cannot be performed. According to the American College of Radiology, the requested diagnostic procedure cannot be used to diagnose osteoporosis based on the quantitative bone mineral density value obtained, since it has never been validated for World Health Organization criteria. Additionally, the requested diagnostic procedure has a higher radiation dose to the patient and is less precise and less accurate than DEXA. According to Placide and colleagues, DEXA and calcaneal ultrasound best predict patients at risk for fracture. According to Lewiecki, DEXA of the spine, hip or forearm is the gold standard technology for diagnosis and monitoring of osteoporosis. The peer-reviewed medical literature consistently states that DEXA is the accepted imaging study for the diagnosis and follow-up of patients for osteoporosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for three Orthovisc injections per knee, every 6 months, for both knees. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient presents with chronic bilateral knee pain. Functional limitations are noted in the patients walking tolerance. Clinical exam findings have been consistent with x-ray evidence of severe osteoarthritis with complete loss of medial joint space on the right (bone-on-bone), greater than 50% loss of medial joint space on the left, and moderate lateral and patellofemoral compartment degenerative changes bilaterally. Reasonable conservative treatment, including medication, activity modification, ice, and corticosteroid injections have failed to provide adequate symptom relief. The patient has undergone bilateral viscosupplementation injections every 6 months with decreased pain and improvement in functional mobility documented. Given the patients previous response, and to assist in delaying total knee replacement, three Orthovisc injections per knee, for both knees, are indicated at this time. However, the medical necessity of future Orthovisc injections cannot be established at this time. Current evidence-based literature would support future Orthovisc injections for both knees if there is documented significant improvement in symptoms for six months or more, and symptoms recur. Therefore, the portion of the request that is for three Orthovisc injections to both knees at this time is medically necessary. However, the portion of the request that relates to future repeat injections should be based on documented positive response to the present series of injections for at least 6 months, and it is therefore not medically necessary at this time.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a lumbar/sacral facet joint block injection. In a systematic review of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain, researchers noted evidence of long-term improvement with the use of therapeutic facet joint nerve blocks and lumbar intra-articular injections. In this case, the patient has a history of relief from intra-articular injections into the lumbosacral facet joints, confirming the source of pain. Given current medical literature, the requested service is medically indicated. Therefore, a lumbar/sacral facet joint block injection  is medically necessary for the treatment of this patient. 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 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.