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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter closure of a patent foramen ovale using a cardiac occlusion device. While current medical literature supports patent foramen ovale (PFO) closure as superior to antiplatelet therapy for preventing future ischemic events, the patients selected for clinical trials comparing PFO closure to antiplatelet therapy all had evidence of definite ischemic infarcts. In this case, the patient had only clinical symptoms and the records did not include evidence to support a diagnosis of cryptogenic stroke. In this clinical setting, there is a lack of evidence in current medical literature to determine if antiplatelet therapy alone may be superior or equal to PFO closure. PFO closure may be appropriate if there are recurrent symptoms or if the patient experiences another a transient ischemic attack while on antiplatelet therapy in the absence of any other etiology such as paroxysmal atrial fibrillation. Therefore, transcatheter closure of a patent foramen ovale using a cardiac occlusion device is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested transcatheter closure of a patent foramen ovale using a cardiac occlusion 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 service 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 1 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in 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.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested Harvoni (ledipasvir-sofosbuvir) tablet 90/400 mg for treatment of his hepatitis C virus.   Findings:  Two physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the guidelines further indicate that Harvoni is recommended for treatment- naive patients with HCV genotype 1a infection. In this case, the patient has a HCV genotype 1a and is treatment-naive. Therefore, treatment with Harvoni is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female who has a history of hyperlipidemia, depression and insomnia. She has been on Lipitor 40mg and Zetia 10mg. She was initially started on therapy because her LDL was 217. With Lipitor 40mg alone her LDL decreased to 163. With Lipitor 40mg and Zetia 10mg her LDL was 65. At issue is whether Zetia is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted documentation indicates the patient has hyperlipidemia. There is no history of coronary artery disease or risk equivalent (diabetes), and no history of hypertension. By NCEP ATP III guidelines, the optimal LDL is below 130. Given the patients low risk factor profile, the formulary medications offered by the Health are likely to be sufficient to bring the patient to an appropriate LDL level.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: Overturned

A 35-year-old male enrollee has requested speech therapy services for the treatment of his voice problems. Findings:  The physician reviewer found that this patients condition is related to chronic dysphonia, superior laryngeal nerve paresis, muscle tension dysphonia, vocal fold varicosity, and bilateral superior laryngeal nerve paresis and is not purely related to reflux laryngitis. The therapy at issue was requested and performed under a physicians order and oversight. The treatment was medically reasonable and necessary with an expectation for practical improvement. The patient had an identified condition of the vocal apparatus and the therapy provided was consistent with the standard of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for metal toxicity test. Findings:  The physician reviewer found that the medical literature is limited as to case reports of heavy metal toxicity from the release of nickel from a birth control implant device or in cases of nickel contact allergen sensitization.  Metal toxicity testing is not a useful or confirmatory test for the evaluation of the patients medical condition. Moreover, this type of test cannot fully explain the constellation of symptoms experienced during the implantation of the birth control device. Current guidelines and recommendations for symptomatic patients with a positive patch test to metals are lacking. The decision regarding implant revision following positive patch results can only be made after a thorough discussion between the patient and the treating provider.  In this case, the identification and avoidance of contact with the presumed offending agent, the birth control implant, by the patient was the key to successful resolution of her symptoms. The Practice Parameter Guidelines on contact dermatitis suggest that recovery is possible if the agent is identified and avoided. Given the symptom resolution, no further intervention is needed in this case. The symptoms reported by the patient, which included vaginal burning, fatigue, head and neck pain, are non-specific for contact allergy to nickel or another heavy metal, such as copper. Not having pre-implant metal toxicity levels to compare to, this renders post-implant metal toxicity levels a challenge to interpret and inconclusive.  Apart from contact with a birth control implant device, heavy metal exposure, to either nickel or copper, can be derived from a variety of different sources, including dietary, inhalation, or orthodontia.  Therefore, a direct link of metal toxicity to a birth control implant cannot be determined. Final Result: The reviewer determined that the requested services are 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 allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old man who was diagnosed with gastric cancer in 1997. He had a subtotal gastrectomy in July 1997. He was then treated with chemotherapy, but suffered a recurrence in 1998. The patient underwent a complication gastrectomy, lymphadenectomy, and intraoperative radiation in July 1998. He had several complications including aortogastric fistula and upper abdominal bleeding. He had further upper GI bleeding episodes that were treated with surgery in 1999. Sometime after that, he was started on Procrit injections to maintain his hemoglobin.  The submitted information includes several hemoglobin determinations, including the following: 12/30/02: Hb 14.9; 3/26/03: Hb 11.7; 10/3/03: Hb 12.4; and 1/26/04: Hb 12.7. The patients iron studies have been normal. A request has been made for authorization and coverage for continued use of Procrit. The Health Plan has denied the request due to a lack of medical necessity.Procrit is an injectable form of erythropoietin given to raise the hemoglobin level primarily in patients deficient in natural erythropoietin. It is of value in patients with cancer who are receiving chemotherapy and is commonly used in such patients when they are anemic. Though there is some controversy as to what level of hemoglobin should serve as an indication for the use of Procrit, it is clearly not indicated with a hemoglobin above 12, as appears to be the case with this patient. Thus, there will be no benefit to this patient from the use of Procrit. Patients without a stomach have major difficulty in absorbing vitamin B12 and iron so they should be treated with these supplements. Should the patients hemoglobin fall, particularly down close to or below 10, then use of Procrit should be reinstituted.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested implanted hormone pellets for medical treatment of her medical condition.  Findings:  Three physician reviewers found that the issue of testosterone pellet therapy is addressed by several references, often in conjunction with the discussion of bioidentical and/or compounded hormone therapy, as these pellets are compounded products and not produced by a pharmaceutical company.  She is currently being treated with multiple compounded hormones and various herbal remedies, none of which are FDA approved.  If it was decided that hormonal therapy was indicated, there are many FDA approved estrogen preparations, including oral, transdermal and transvaginal routes, as well as an estrogen/testosterone oral preparation that does not appear to have been tried, and could be used as an alternative to the compounded estrogens and testosterone pellet therapy.  In summary, the superior efficacy of implanted hormone pellets has not been demonstrated, and there are potential safety and side effect concerns.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy. The requested speech is medically necessary for treatment of this patients medical condition. The patient has severe receptive and expressive language impairment due to Down syndrome, with co-existent autism spectrum disorder. Speech and language impairment are typically found in patients with Down syndrome, and that impairment of expressive language is significantly worse than receptive language. Ongoing speech therapy in adolescents and young adults with Down syndrome enable their integration into the work force and community. Although he is still below the first percentile for both receptive and expressive language, his functional language has significantly improved in excess of normal expected maturation. The patient is committed to continuing speech therapy, and follows recommendations given by the provider. Given these findings, the requested speech therapy is medically necessary for treatment of the patients severe receptive and expressive language impairment. 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 and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested a Vest Airway Clearance System for the treatment of her medical condition. Findings:  Two physician reviewers found that this is a patient with severe progressive lung disease which has been minimally responsive to previous standard therapies (antibiotics and steroids).  Although additional large scale studies need to be done, chest physiotherapy is a standard of care for patients with pulmonary disease.  Unfortunately, this patient is alone and does not have the home support to undergo chest physiotherapy.  A Vest Airway Clearance System is consequently an appropriate therapy option for her.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee replacement surgery. Findings:  The physician reviewer found that in the medical literature, a study  concluded that a BMI greater than 40 kg/m2 may be used as a cutoff to help guide patient education and treatment options for primary total knee arthroplasty. Another study observed an increased risk of wound infection and deep vein thrombosis in obese patients. Study results did not advocate surgery be given without consideration of BMI, but indicated that universal denial of surgery based on BMI is unwarranted. This patient presents with chronic bilateral knee pain, right greater than left. Clinical examination findings are consistent with radiographic evidence of severe joint space narrowing in the medial and lateral compartments of both knees, right more severe than left, and moderate degenerative changes in the patellofemoral joint. There is detailed evidence of conservative treatment, including activity modification, medications, home exercise, attempted weight loss, and corticosteroid injections without sustained improvement. However, the patients current BMI is documented as greater than 50 kg/m2. Additional comorbidities include atrial fibrillation, chronic obstructive pulmonary disease, and hypertension. Overall, there is no compelling rationale presented to support the medical necessity of total knee replacement in a patient with a BMI over 50 kg/m2. Therefore, the requested knee replacement surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested extracorporeal shock wave therapy for the treatment of her chronic plantar fasciitis. Findings:  Two physician reviewers found that there is some evidence in the literature that extracorporeal shock wave therapy can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects. In addition, there have been some conflicting results among the randomized controlled studies. A recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of extracorporeal shock wave therapy for some patients with plantar fasciitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of his elevated prostate specific antigen (PSA).  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. The American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines do not recommend use of prostate cancer antigen 3 (PCA3) testing for screening or diagnosing prostate cancer. In addition, there is a lack of clinical studies demonstrating that PCA3 testing is sufficiently accurate to diagnose or exclude the presence of prostate cancer. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing 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 urology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of his medical condition. Findings: The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested medication.  Per the medical records, non-opioid treatment options have not been exhausted.  The records do not document behaviorial therapy, despite much research to support its use.  In this patients case, non-opioid medications have been optimized.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Norco is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. Findings:  The physician reviewer found that Based on the available documentation, the RTC services provided were not medically necessary for treatment of this patients medical condition. The patient showed minimal post-acute withdrawal symptoms, there was no evidence of suicidality, homicidality, or violence or aggression towards others, and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. The patient was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care in a less restrictive treatment setting. He was motivated and appeared to be working the program. He had a sponsor. He was three days post discharge from detoxification and had relapsed on one triazolam. Moreover, he had coping skills with the capability of implementation. He could have continued treatment and recovery on an ambulatory basis such as PHP. As of the date of service in question, the patient no longer met the American Society of Addiction Medicine (ASAM) clinical guidelines for residential level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Overturned

A 30-year-old female enrollee has requested allogeneic stem cell bone marrow transplant for treatment of her Crohns disease. Findings:  Three physician reviewers found that in this patients case, the requested allogeneic stem cell bone marrow transplant is likely to be more effective than other available options.  This patient has exhausted standard regimens for the treatment of Crohns disease.  Her condition has been resistant to multiple standard treatment options.  There is some evidence in the medical literature indicating that allogeneic stem cell bone marrow transplant may be effective in controlling Crohns disease in this clinical setting.  There are limited options for the treatment of this patient.  In sum, the requested services are likely to be of greater benefit than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis (CPT 77063) for evaluation of her medical condition.  Two physician reviewers found that although there is a lack of long term studies proving an increased survival rate when digital tomosynthesis has been added to mammographic images at screening, the addition of the technique has become the standard among providers due to a decrease in callbacks and increased rate of detection of small cancers. Thus, the addition of the technique is considered more beneficial to the patient than screening mammography alone. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be 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.