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

A 60-year-old male enrollee has requested Cialis 5 mg to be taken daily for the treatment of his erectile dysfunction secondary to prostate cancer. Findings:  The physician reviewer found that the scientific literature reveals no references supporting the medical necessity of a daily dosage of Cialis. The effectiveness of Cialis, Levitra and Viagra are very similar. Results vary from one study to another, but a few have shown better results with Cialis. Daily dosage, however, has not been shown to be medically necessary. The medication enhances a receptor by being a PDE-5 inhibitor. It has not been shown to improve erectile dysfunction if taken on a daily basis. Daily use does allow the patient to take a lower dose and have the receptor inhibitor present on a continuous basis. The article by Wang concludes that further studies are needed to assess the use of Cialis on a daily basis for efficacy in post-radical prostatectomy patients. The medical need for a daily dosage has not been established as concluded in the study by Wang.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested laparoscopic duodenal switch for treatment of her severe obesity.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery in this case. According to the American Society for Metabolic & Bariatric Surgery (ASMBS), the duodenal switch is considered a standard primary treatment for morbid obesity and clinically severe obesity. This patient is morbidly obese with a BMI that is greater than 40 and has already been approved for weight loss surgery. This patient meets generally accepted criteria for medical necessity of bariatric surgery at this time. Based on standards within the field and published medical literature, this patient should be a candidate for any primary treatment which would include DS. All told, the medical necessity of the requested laparoscopic duodenal switch procedure has been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for authorization and coverage for implantation of a Vagus Nerve Stimulation (VNS) Therapy System. The U.S. Food and Drug Administration (FDA) approved the use of the VNS Therapy System in 2005 as a device/treatment modality for the treatment of a refractory episode of major depressive disorder. Current medical literature supports the use of VNS as a pathway for adjunctive and alternate treatment for severe, recurrent, refractory major depressive disorder, and as safe and effective in the long-term. In this case, the submitted records document that the patient meets the criteria for a diagnosis of major depressive disorder, and that the refractory designation of the condition, having completed 12 treatment sessions of ECT without remission of symptoms. Therefore, implantation of a VNS Therapy System is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested authorization and coverage for implantation of a Vagus Nerve Stimulation (VNS) Therapy System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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

A 62-year-old male enrollee requested anesthesia (monitored anesthesia care (MAC)) for medical treatment of his colonoscopy and upper endoscopy.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested Lap-Band surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient has a BMI of 40. This meets the recommendations set by the National Institutes of Health for weight loss surgery. The patient has also documented multiple attempts at weight loss, including numerous diets, over-the-counter pills and phentermine. Weight loss surgery has been demonstrated to be superior to diet and exercise plan for the treatment of morbid obesity. It is not likely that the patient will achieve and maintain adequate weight loss without surgical intervention. This patient is an appropriate candidate for the Lap-Band procedure, and the procedure is medically indicated to treat her morbid obesity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast reduction surgery for treatment of the enrollees bilateral breast hypertrophy. Findings: The physician reviewer found that this patient presents with well-documented symptomatic macromastia that has failed reasonable conservative management. Her examination and degree of resection planned are supportive of her clinical functional deficit. She would likely benefit significantly from breast reduction surgery. In addition, the American Society of Plastic Surgeons (ASPS) guideline states that reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Hammond and Loffredo noted that the presence of common symptoms related to strain on the upper torso attributable to the weight of the breasts must be documented. These symptoms can include headaches, neck pain, back pain, submammary intertrigo (particularly during the warmer months), painful bra strap marks with grooving and possible associated ulnar paresthesias caused by pressure on the brachial plexus, breast pain, difficulty wearing clothing that fits proportionately. This patient satisfies these criteria as there is evidence of well-documented, chronic back and shoulder pain and chronic intertrigo with failure of reasonable conservative management including analgesics and dermatologic treatment. Moreover, she has chronic headaches, evidence of chronic intertrigo with failure of dermatologic treatment and shoulder grooving as well. Her examination detail, planned degree of resection and review of the photographs are supportive of her significant macromastia. Based on this, her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. Furthermore, a 500-600 gram resection from each breast is consistent with a significant breast reduction. In summary, this patient has functional problems that are directly related to her significant macromastia. Breast reduction is a well-known procedure that will directly addresses this patients functional compromise. Thus, given the patients diagnosis of shoulder pain, intertrigo and macromastia, the requested breast reduction surgery is supported as medically necessary.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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is peer-reviewed literature that supports the use of three-dimensional (3D) breast tomosynthesis in addition to mammography alone. Tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers, since underlying dense tissue may be separated from mass/architectural distortion with the technique and was thus more likely to have been beneficial to this patient than had the mammogram been done with two-dimensional (2D) imaging only.  Final Result: Two 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

The is a 46-year-old male patient who has Crohns disease and reports that although he has tried three different medications for this disease he continues to be symptomatic. He indicates that the use of Omacor has improved his symptoms by 80%. At issue is whether Omacor is medically necessary for treatment of the patients medical condition.The use of Omacor is not medically necessary for this patient. There are no double blind prospective studies demonstrating that Omacor is efficacious in patients with Crohns disease. There is only anecdotal information regarding the possible benefits of the drug. Omacor is not the standard of care is this setting and there is insufficient data supporting its efficacy to warrant its use in this case. Therefore, 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: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested robotic prostatectomy with urethropexy for the treatment of his prostate cancer. Findings:  Two physician reviewers found that radical prostatectomy is appropriate therapy for localized prostate cancer in a healthy male with no contraindications. It is the gold standard in terms of cancer outcomes and cure. The complications which can occur with this surgery include erectile dysfunction, urinary incontinence and intraoperative blood loss. The addition of robotic assistance has increased the facility, speed and safety of this operation. There are now multiple centers with extensive experience doing robotic prostatectomy, and the frequency with which it is performed has exploded in the last few years. In 2008, more than one half of the 100,000 radical prostatectomies that will be done will be done laparoscopically with robotic assistance. The outcomes for cancer cure and continence appear to be equal to the open procedure. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it to be superior. This procedure is not experimental and is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg, two tablets daily. This patients records do not document an adequate treatment with topical steroids. Moreover, the patient has not tried and failed the Health Plans preferred formulary agents, Enbrel, Humira and Cosentyx. As there is no contraindication or documented history of adverse effects from treatment with the preferred agents which are U.S. Food and Drug Administration (FDA) approved for this patients medical condition, the requested Otezla is not medically necessary. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right breast capsulotomy for treatment of the enrollees infiltrating ductal carcinoma and not reconstructive in nature.Findings:  The physician reviewer found that The Womens Health and Cancer Rights Act (WHCRA) mandates coverage for all stages of breast reconstruction. The WHCRA states that mastectomy may require certain services relating to the mastectomy and coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema. The records provided for review document that this patient has continued deformities following her breast cancer reconstruction, which is an abnormal condition. The abnormal condition is due to breast cancer, and correction of the condition is a stage of her reconstruction. Moreover, the requested procedure will provide a more than minimal improvement in the patients appearance. As noted in the medical literature, the outcome and quality of breast reconstruction can change over time. Breast reconstruction is now understood to be a multi-stage process including revisions. In this patients case, the requested revision of the implant pocket is one medically necessary stage of her reconstruction to restore her breasts to her pre-mastectomy appearance. Given these findings, the requested right breast capsulotomy is supported as medically necessary and reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. 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

An enrollee has requested authorization and coverage for transoral incisionless fundoplication with EsophyX device. Based on the records provided for review, this patient has not exhausted standard conservative therapies for the treatment of GERD. Specifically, there is a lack of documentation that the patient has attempted lifestyle modification or maximal medical therapy. Moreover, there is a lack of peer-reviewed medical literature or guidelines reporting that transoral incisionless fundoplication is superior at long-term follow-up when compared to other standard operative techniques such as Nissen fundoplication. All told, the requested transoral incisionless fundoplication with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Vertiflex procedure. This patients medical condition is lumbar spinal stenosis. His provider has recommended the Vertiflex procedure since the patients pain did not substantially improve with medications, physical therapy, and epidural steroid injections. Lumbar stenosis may be treated with multiple modalities including traditional decompression, with or without fusion. Newer techniques, including the minimally invasive lumbar decompression and interspinous process devices, are also available for implementation. The Vertiflex procedure is a non-fusion device that is used in minimally invasive treatment of lumbar spinal stenosis. Moojen and colleagues discussed some important differences between Vertiflex and traditional, open decompression. Per the authors, the rates of reoperation in patients with the Vertiflex device were considerably higher than those in the decompression group. Open decompressive lumbar spine surgery is likely to be of greater benefit to this patient than the Vertiflex procedure, based on the available peer-reviewed medical literature and clinical trial outcomes. Accordingly, the requested Vertiflex procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Vertiflex procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Orthovisc injections, one (1) per week, for three (3) weeks.Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of hyaluronan therapy for treatment of the patients medical condition. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with severe knee osteoarthritis who have failed conservative treatment, and state there is no maximum amount of injections established by high quality scientific evidence. In this case, the patient presents with recurrent right knee pain and swelling. The patient reports that the patient can barely walk or perform daily activities due to the pain and swelling. Clinical examination findings are consistent with radiographic evidence of severe tri-compartmental osteoarthritis of the right knee, with complete loss of the lateral joint space. Reasonable conservative treatment, including activity modification, medications, and corticosteroid injections, have failed to provide adequate relief. Prior viscosupplementation injections have provided complete pain relief and functional restoration for six months. The treating provider has recommended continued viscosupplementation injections to delay total knee replacement due to the young age of this patient. Therefore, the requested for hyaluronan/Deriv Orthovisc, for intra-articular injections per dose, one (1) per week, for three (3) weeks is medically necessary for treatment of the 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 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.