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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings: Three physician reviewers found that this patient has treated diabetes and hypertension. The patient is currently on Vytorin therapy and simvastatin 20 mg with ezetimide. The patient has had multiple advanced lipid profile testing in the past as well. In situations where there is moderate cardiovascular risk and additional clinical risk factors are present, a single measurement of advanced lipid parameters may be useful in deciding whether to start lifelong statin lipid lowering therapy. However, in this instance, the patient already has an indication for high dose statin therapy based on her age, treated diabetes, hypertension and the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines (Greenland, et al). In addition, her low density lipoprotein cholesterol (LDL-C) and high density lipoprotein (HDL) are also being followed as well. There is a lack of data or published guidelines to suggest that ongoing repeated measurements of these advanced lipid profile values provide either prognostic or additional clinical value as opposed to the current risk factor based guideline medication regimens. All told, based on current published ACCF/AHA guidelines and published data, repeated advanced lipid profile monitoring does not provide additional actionable clinical information compared to standard profiles and risk assessments (Stone, et al; Mora, et al). Thus, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 54-year-old female enrollee has requested continued use of methadone HCl for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The records noted aberrant behavior with opioid medications, including a urine toxicology positive for cocaine.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The medical evidence does not support the requested medication in this clinical setting.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high-dose opiates might induce abnormal pain sensitivity and tolerance.  All told, continued use of methadone HCl is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Cologuard test for evaluation of the enrollees risk of colon cancer. Findings:  The physician reviewer found The Cologuard test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The documentation submitted for review does not support the testing at issue as more effective than standard colon screening strategies. In addition, the patients reported change in bowel pattern raises concern for colonic pathology that may evade detection by Cologuard. For the reasons provided, 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: Two of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. EMDR is a therapy in which patients generate exposure to trauma via imagery while performing horizontal saccadic eye movements. A skilled therapist assists the patient in decompressing the anxiety burden stemming from the traumatic image or memory. EMDR is not recommended for the treatment of obsessive-compulsive disorder or psychosis (Koran, et al), but it is a well-accepted treatment for post-traumatic stress disorder (PTSD) (McNally). In this case, the record does not substantiate the diagnosis of PTSD. Thus, the disputed service is neither appropriate nor reasonably expected to improve the patients condition based on the data provided. Therefore, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requests authorization and coverage for the prostatic urethral lift implant/UroLift surgery. He has a history of nocturia and erectile dysfunction. While hospitalized for an upper gastrointestinal bleed, he developed acute urinary retention and had an indwelling catheter placed.Findings: the physician reviewer found that  the catheter was removed and failed voiding trials, despite taking two Flomax capsules per day. A cystoscopy revealed evidence of urethral strictures, and an enlarged, inflamed prostate.  He was diagnosed with benign prostatic hypertrophy (BPH) with urinary retention.  He now requires a catheter to empty his bladder that has to be changed every 30 days.  The physician discussed the risks and benefits of transurethral resection of the prostate (TURP) versus UroLift surgery. The enrollee wants to have the UroLift procedure because it is a minimally invasive procedure with less complications than standard TURP.  UroLift was approved to treat benign prostatic hypertrophy (BPH) symptoms, with no evidence of an enlarged median lobe and overall prostate size of <80 grams.  The UroLift indications now include males as young as 45-years-old, and a median lobe was now acceptable for treatment with UroLift.  Guidelines mention UroLift as an acceptable treatment option for lower urinary tract symptoms secondary to BPH in men who are intolerant of medical therapy or have a desire to preserve sexual function/ejaculation. Transurethral resection of the prostate (TURP) will often result in lifelong retrograde ejaculation due to resection of the bladder neck. Medical studies have shown the voiding improvement after UroLift can be sustained for up to five years. Although UroLift and TURP have not been studied in a head-to-head comparison, UroLift is an outpatient procedure, is less likely to result in postoperative bleeding than TURP, and has a greater likelihood of preserving sexual function/ejaculation.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: 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: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee has requested a left total ankle replacement for the treatment of her degenerative joint disease and osteoarthritis. Findings:  Two physician reviewers found that total ankle replacement procedures had many problems after the introduction of the procedure, but more recent designs have shown better initial results. However, there are few reports of results over time, and many of the reports have not been validated by independent and controlled studies. Several studies are in progress to evaluate the procedure and to compare it to fusion, but the results are not yet available.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male has requested acute rehabilitation care for treatment of his medical condition status post intracranial hemorrhage with right sided hemiparesis.  Findings:  The physician reviewer found that it is generally agreed that a patient meets guidelines for acute inpatient rehabilitation when the following conditions are met: 1) Requires close physician supervision in order to care for multiple complex medical conditions; 2) requires the coordinated care of skilled therapists from multiple disciplines; 3) has the ability to participate in an intensive rehabilitation program and progress toward defined goals at a predictable and reasonable rate; 4) requires inpatient care and 24-hour rehabilitation nursing care; 5) could not achieve similar functional recovery in a less intensive setting. In the case under review, the patient sustained a severe brain injury secondary to ICH. He demonstrated the ability to participate and achieve functional gains in an intensive rehabilitation setting. He also appeared to benefit significantly from close physician monitoring for the early detection and management of medical complications. While in the skilled facility setting, the patient developed multiple medical complications requiring repeated hospitalizations. Recovery from ICH can be slow and significant recovery has been observed up to six months to one year following presentation. The patient therefore meets the generally accepted guidelines for acute inpatient rehabilitation and continues to have the potential to achieve further functional recovery.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested motility clinic treatment for treatment of his history of abdominal pain and jaundice.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  There is no justification in the medical records that formal evaluation for a gastrointestinal motility disorder is warranted. Additionally, there is a lack of documentation demonstrating what specific gastrointestinal motility disorders are of concern in this patients case. There is a lack of objective evidence documented in the medical record supplied for review demonstrating that the patient has a gastrointestinal motility disorder.  There is no documentation of weight loss, vomiting, or symptoms of intestinal obstruction or pseudo-obstruction.  All told, the requested motility clinic treatment is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81519). Findings:  The physician reviewer found that Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In this case, there is a 15% chance of recurrence, and it is this 15% that needs adjuvant chemotherapy. If all patients were treated with chemotherapy, then 85% of the patients would have never needed it. National Comprehensive Cancer Network (NCCN) guidelines support the use of Oncotype DX genetic testing. The Oncotype DX test is well validated by applying it in the patients of the NSABP B-14 trial, where 71% of these were post-menopausal, and the test has been validated over the years since completion of this trial. In this case, the patient was HR-positive and HER2-negative and had Oncotype DX Breast Recurrence Score genetic testing (CPT 81519) performed consistent with NCCN guidelines. Under these circumstances, the genetic testing (CPT 81519) at issue was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in medical oncology, 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 been diagnosed with left knee osteoarthritis. The provider noted the patient has a remote history of left knee medial meniscus arthroscopic surgery. The provider noted the patient has been treated with a platelet rich plasma injection and physical therapy. The patient reported a prior Monovisc injection administered in September 2019 provided several months of pain relief. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted the patient has been treated with a triamcinolone acetonide injection, Motrin, and physical therapy, with minimal relief. The patient has requested authorization and coverage for a Monovisc 88 mg/4 mL injection for the left knee. The Health Plan denied the request and reported that the requested service is not medically necessary for the treatment of this patient. At issue in this case is whether a Monovisc 88 mg/4 mL injection for the left knee is medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of pain relief from a prior viscosupplementation injection with Monovisc in September 2019, which provided several months of pain relief. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, such as corticosteroid injections, Motrin, and physical therapy. The medical evidence supports the requested service in this clinical setting. Therefore, a Monovisc 88 mg/4 mL injection for the left knee 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for methylenetetrahydrofolate reductase (MTHFR) gene mutation testing for evaluation of the enrollees inability to break down a variety of different substances. Findings:  The physician reviewer found that in recent years, genetic polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene have been associated with adverse reactions to the smallpox vaccine. Similarly, mutations in the MTHFR gene have also been implicated in medical conditions. While MTHFR mutations have been implicated in several disease processes, routine sequencing for MTHFR mutations is not considered standard of care. Recent meta-analyses have disproven an association between hyperhomocysteinemia and risk for coronary heart disease and between MTHFR polymorphism status and risk for venous thromboembolism. There is growing evidence that MTHFR polymorphism testing has minimal clinical utility even in the setting of thrombophilia. All told, the requested MTHFR gene mutation testing is not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is 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 pediatrics with sub-specialty certifications in neurodevelopmental behavioral pediatrics and genetics 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 authorization and coverage for Xeljanz 5mg tablet twice daily.Findings: Three out of three physician reviewers found that the requested Xeljanz 5mg tablet twice daily is likely to be more beneficial than any other available standard treatments for the patients medical condition.The available treatment options for alopecia areata (AA) are quite limited. This is especially true for diffuse/multifocal involvement, where standard therapies such as topical steroids, intralesional kenalog, contact immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and cyclosporine) are more often than not less than satisfactory and associated with side effects. Although there is no significant data yet from randomized clinical trials (which are currently underway), there is substantial clinical evidence to support the use of oral JAK kinase inhibitors such as tofacitinib for alopecia areata. In one open label pilot study, 8 out of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool scoring. Another retrospective study consisted of patients with alopecia areata with at least 40% scalp hair loss who were treated with tofacitinib. This study found that 77% achieved a clinical response and that 58% of patients had an approximately 50% change in SALT score. There have been minimal adverse effects reported to date. Moreover, these results are superior to reported results for contact immunotherapy and systemic steroids. Thus, the requested Xeljanz 5mg tablet twice daily is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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

A 56-year-old female enrollee has requested Olysio 150mg oral capsule in combination with Sovaldi for treatment of her chronic hepatitis C genotype 1 infection.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination in this patients case.  Two new drugs for the treatment of hepatitis C virus infection are Sovaldi, a nucleotide analog polymerase inhibitor and Olysio, an oral protease inhibitor.  Prior to the introduction of Sovaldi, treatment options for interferon-ineligible hepatitis C patients were limited.  There is sufficient support for Olysio 150mg oral capsule in combination with Sovaldi in this clinical setting.  The requested medication combination, with or without ribavirin, has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C genotype 1, including patients with cirrhosis.  The treatment regimen of Olysio with Sovaldi carries the joint recommendation of the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America for treatment-experienced hepatitis C genotype 1 patients who are interferon-ineligible.  All told, Olysio 150mg oral capsule in combination with Sovaldi is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested Oncotype DX genotype testing for an evaluation of her breast cancer. Findings:  Two physician reviewers found that Oncotype DX testing is a 21-gene signature performed on breast cancer specimens. This assay is a validated tool in determining the recurrence risk in patients with ER+, node negative breast cancer. This patient meets the clinical criteria upon which this test is based. The use of this assay in this clinical situation is well supported by the peer-reviewed scientific literature. Furthermore, the National Comprehensive Cancer Network (NCCN) endorses the use of this assay in this patients particular clinical setting.