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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for dosage escalation of Entyvio 600 mg infusion every four weeks. Findings:  The physician reviewer found that the patient was treated with Entyvio for inflammatory bowel disease and initially appeared to have a clinical response to dosing every six weeks. Telemedicine notes reported that the patients bowel movements fluctuated from three to four times on a good day, to bad days when she lost count of bowel movements. Notes reported that the patients vedolizumab level was 7.0, and the provider recommended an increased dosage of 600 mg of Entyvio every four weeks. The U.S. Food and Drug Administration (FDA) recommends dosage of Entyvio for patients with ulcerative colitis and Crohns disease at zero, two, and six weeks, and every eight weeks thereafter. Sandborn and colleagues note that the efficacy of vedolizumab, an 47 integrin antibody, in Crohn's disease is unknown. The authors further noted that adverse events were more common with vedolizumab-treated patients with active Crohn's disease than those receiving a placebo. In this clinical setting, there is a lack of current medical literature supporting the requested dosing frequency as safe and effective for treatment of the patient's medical condition. Therefore, dosage escalation of Entyvio to 600 mg infusion every four (4) weeks is not likely to be more beneficial than any other available standard treatment for the patients medical condition.Findings:  Two of the three physician reviewers found the requested dosage escalation of Entyvio to 600 mg infusion every four (4) weeks 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 medication regimen 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, 2, and 3 are board certified in internal medicine with sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure for treatment of the enrollees bilateral keratoconus. Findings:  The 3 physician reviewers found that there is support in the medical literature for the superior efficacy of the services at issue in this patients case. Based on the patients vision loss and previous treatment with glasses and contacts, the cross-linking was the most appropriate and effective treatment available. There is a large body of available literature in support of corneal collagen cross-linking for treatment of this patient. The evidence shows corneal collagen cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is limited treatment options available to slow or halt disease progression. Therefore, collagen cross-linking for treatment of this patient was likely to have been superior to the available standard options. Final Result: The 3 reviewers determined that the services at issue were 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 reviewer number one is board certified in ophthalmology 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.Physician reviewer number two is board certified in ophthalmology 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.Physician reviewer number three is board certified in ophthalmology 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 reimbursement for Testopel implants (subcutaneous testosterone implants, CPT code S0189 quantity 10 and CPT code 11980 quantity 1) for treatment of the enrollee who has a history of low testosterone level. Findings:  The physician reviewers found that there is sufficient support in the medical literature for the services at issue. Testopel has been approved by the U.S. Food and Drug Administration and has been commercially available since 1972.  The medical literature indicates that Testopel offers a longer acting time to maintain normal levels of testosterone.  It does not require a daily or biweekly application like testosterone gels or testosterone injection.  Testopel maintains a more steady level and availability of testosterone for months after insertion. Testopel has distinct advantages over other treatment modalities for low testosterone and should be considered as one of the available standard treatment options by which low testosterone in men can be treated. All told, the Testopel implants (subcutaneous testosterone implants, CPT code S0189 quantity 10 and CPT code 11980 quantity 1) were likely to have been superior over other standard methods available for the treatment of this patients medical condition. Final Result: Two of three reviewers determined that the services at issue were 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 number one, two, and three are board certified in urology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Sources reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Orthovisc injections are supported as medically necessary for treatment of this patients knee osteoarthritis. 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for sleeve gastrectomy procedure for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for sleeve gastrectomy procedure is medically necessary for treatment of the patients morbid obesity. The patient meets standard adolescent bariatric surgery guidelines, including International Pediatric Endosurgery Group (IPEG) guidelines. These criteria generally require a BMI of at least 50 or 40 with certain co-morbid conditions. In this case, the patient has a BMI that is 64 kg/m2 with sleep apnea. The patient was cleared from orthopedic and medically at full growth and also completed dietary and psychological evaluation. The patient has failed dietary efforts in the past. The risks of surgery are outweighed by the potential benefits of weight loss and treatment of morbid obesity. As such, the medical necessity for the requested procedure is indicated in this clinical setting. Final Result: The reviewer determined that the requested procedure 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 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

A 59-year-old female enrollee has requested Sirtex radio embolization for the treatment of her cholangiocarcinoma. Findings:  Two physician reviewers found that although the medical literature is sparse on this topic and current NCCN Guidelines are somewhat limited in their recommendation, cholangiocarcinomas are relatively rare tumors and are not well studied. In this particular case, SIRT has been recommended by the patients multidisciplinary team as the best approach. I concur with this assessment as there is no evidence that any alternative standard therapy will be superior in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested surgery, nerve decompression (CPT Codes 64712, 64727, 64704, 64708 x 4) for treatment of his nerve entrapment of the left leg.  Findings:  The physician reviewer found that review of the documentation provided indicates the patient is a diabetic with neuropathy and possible nerve entrapment. Diabetics commonly have diabetic peripheral neuropathy due to elevated blood sugar levels. While decompression surgery is clinically indicated for an entrapped nerve, there is no evidence to support the use of nerve decompression for the treatment of diabetic peripheral neuropathy. The records provided do not demonstrate that appropriate diagnostic testing and treatment for an entrapped nerve has been performed. There is no evidence of an MRI and nerve conduction studies to indicate that there is definite nerve entrapment. Thus, based upon the evidence provided, the patient does not meet accepted clinical indications for nerve decompression surgery. Accordingly, the medical necessity of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 26-year-old male who sustained an injury to his knee. He underwent an ACL reconstruction. Postoperatively, a continuous passive motion (CPM device) and related pad were utilized. The patient has requested reimbursement for this equipment, which the Health Plan has denied.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. The CPM machine and related pad were medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested Supartz injections for treatment of his osteoarthritis. Findings:  The physician reviewer found that the patient is not a good candidate for Supartz injections. The arthritis in his left knee is severe and these injections will provide little, if any, relief. A cortisone injection may provide a temporary benefit for the patient. However, considering the patients age and the severity of his arthritis, serious consideration should be given to knee replacement surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested a urology consultation for the treatment of his possible urinary tract infection. Findings:  The physician reviewer found that an evaluation of a male with complaints of urinary frequency and suprapubic pain would in most cases be performed by a primary care physician; workup would include urinalysis, physical examination, and obtaining a prostate symptom score index and voiding dairy. In cases with moderate suprapubic pain, a CT scan could be ordered to rule out a urologic stone. According to Rosenberg and colleagues, this patients symptoms (assuming a negative urinalysis), would likely be treated with alpha one blockers, with or without a 5 alpha reductase inhibitor with re-evaluation in one to three months. All of services are within the scope of expertise of a primary care physician. Generally, if a patient is found to have a large residual amount of urine, a urologic stone, blood in the urine, or poor response to medical therapies with symptoms of prostate enlargement, a urologic consultation is indicated. Based on the documentation provided, this patient does not meet criteria for urologic consultation at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female has requested a breast MRI  for evaluation of her medical condition.  Findings:  Two physician reviewers found that the patient has a positive family history of breast cancer and of Ashkenazi Jewish descent, placing her at significant increased risk of breast cancer. Genetic testing revealed she is BRCA-1 negative. Her mammograms demonstrate extremely dense breast tissue which markedly limits the utility of mammography in her case. The patient had a MRI of the breasts where a suspicious area of enhancement was seen in the left breast. Targeted ultrasound was equivocal at best. She had a follow-up MRI scan which showed a persistent area of enhancement in the left breast. MRI guided biopsy was suggested. She was scheduled for the planned biopsy but the MRI failed to reveal the abnormal area of contrast enhancement. A six month follow-up MRI was recommended to determine if the suspicious area was no longer present. The Health Plan has denied the request for follow-up MRI in six months stating there is no evidence such a close follow-up is beneficial for the patient.This patient is at increased risk of breast cancer during her lifetime with a 20% risk calculated by the Gail model.  Further complicating the issue is her extremely dense breast tissue on mammography, which limits the usefulness of that technique. Targeted ultrasound has proven to be equivocal. In this patients case, the detection of an abnormality deep within the left breast was only seen with MRI. There were two studies which showed the abnormality and the last study failed to demonstrate the same findings. Since the lesion was previously only seen via MRI, it would be prudent to follow the patient at another six month interval rather than waiting a full year to determine if there is a suspicious abnormality requiring sampling. Since the questioned abnormality has only been seen by MRI, this technique should be used as the follow-up tool. No other technique would be of such value to this patient. Additionally, accepted breast imaging guidelines provide support for short term, six-month follow-up in such cases.  In this case, the requested MRI would not be considered a screening exam. It has been requested as an exam to evaluate suspicious or equivocal findings.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for IVIG therapy for treatment of her statin-induced myopathy. Findings:  The physician reviewer found that IVIG is not indicated for this patients condition. This patient likely has statin myopathy, as there is no other obvious cause of myopathy. IVIG is not medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested a 12 week course of Sovaldi and Olysio for medical treatment of her hepatitis C genotype 1.  Findings:  The physician reviewer found that there is no demonstration of advanced fibrosis (stage F3 or greater), by either liver biopsy, elastography, of liver fibrosis panel. The current medical literature does not support treatment with Sovaldi and Olysio in patients with only minimal fibrosis and inflammatory activity. Given the lack of evidence that the patient has advanced fibrosis, the requested medication regimen consisting of a 12 week course of Sovaldi and Olysio is not supported as medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested residential treatment center services for treatment of his depressive disorder, not otherwise specified, and substance dependence disorder. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for residential treatment center services. There is no indication of suicidal ideation during his stay and no evidence of any prior suicide attempts. There were no serious withdrawal symptoms, and the patients living environment was not subversive to sobriety. There is no indication of risk to others and no evidence that he had medical problems which could not have been safely managed on an ambulatory basis.  The patient had not failed a less intensive level of care and did not show indications of any behavior which required containment on a 24-hour basis. Based upon American Psychiatric Association practice guidelines and American Society for Addiction Medicine criteria, residential treatment was not medically necessary during the dates of service at issue.  All told, residential treatment center services provided were not medically indicated in this patients case.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. An overdose has potential for loss of consciousness, tachycardia, prolongation of the QT interval, and hypokalemia with first degree atrioventricular block. In this case, the patient presented with altered mental status that did not reverse with Narcan. The patient had history of depression with psychotic features, which is a difficult diagnosis to treat and is associated with an elevated rate of suicide. The patient admitted to taking an overdose with suicidal intent. The patient was not cooperative with the initial psychiatric evaluation. The patient was placed on an involuntary psychiatric hold. The patient was also being evaluated for a possible blood clot. Considering the patients psychiatric diagnosis, reluctance to engage in a therapeutic discussion, and the patients need for further medical assessment to rule out potentially life-threatening conditions, the services at issue met the criteria for emergency services as defined above. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for testosterone cypionate 200 mg injection every seven (7) days. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients testicular dysfunction. The submitted documentation supports the medical necessity of the requested medication regimen. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored every three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. Therefore, the requested testosterone cypionate 200 mg injection every seven (7) days is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.