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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. In treatment naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  Additionally, treatment of patients before they progress to cirrhosis is advantageous. Lower cure rate has been reported in patients with cirrhosis. Treating patients at an earlier stage of liver fibrosis results in significant improvement in life-years, specifically, treatment with Harvoni resulted in a 66% reduction of overall liver-disease-related complications when patients were treated at fibrosis score F2 versus F3F4, and 82% reduction in complications with treatment at F0F1. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni for 12 weeks is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera 240 mg. The current medical evidence supports the requested medication in this clinical setting. Tecfidera has been approved by the U.S. Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis. The mechanism of action of Tecfidera is different than Gilenya, Glatopa and glatiramer. The relative relapse reduction rate of Gilenya and Tecfidera is nearly equal. The relapse reduction rate of Tecfidera is better than Glatopa and glatiramer. Per the records, this patient is needle phobic, and she does not desire to pursue treatment with Gilenya due to risk of unpredictable progressive multifocal leukoencephalopathy. Selecting a medication that the patient finds more tolerable is likely to increase compliance. Therefore, Tecfidera 240 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation services. Findings:  The physician reviewer found that Breshears and colleagues note that dexamethasone is a standard treatment for cerebral edema after brain tumor surgery, however, side effects including diabetes, hypertension, and insomnia can negatively impact the quality and safety of care provided to patients. Jessurun and colleagues note that dexamethasone has long been a staple of neurosurgical treatment used to control peritumoral edema and focal neurological symptoms. The authors note that the use of dexamethasone is associated with a variety of adverse events including muscular weakness, hyperglycemia, cushingoid symptoms, mental disorders, and gastrointestinal ulceration. These adverse effects are known to be related to cumulative dose and duration of therapy. In this case, the patient is status post meningioma resection, and reported stopping steroid use due to insomnia and other putative adverse effects. She was admitted to the emergency department with an altered mental state that was attributed to the cessation of steroids. The records noted an improvement in mental health and functional status after her steroids were restarted with a tapering schedule. While the patient required contact guard assistance for transfers and some cues, the records noted medical stability and functional improvement. In this clinical setting, given that the patients rehabilitation needs can be met at a less intensive setting of care, the requested services are not medically indicated. Therefore, acute rehabilitation services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 physical medicine and rehabilitation 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 a referral to a neurologist for evaluation of his medical condition.   Findings:  The physician reviewer found that the requested referral to a neurologist is medically necessary for treatment of the patients medical condition. This patient presents with numbness and tingling. His treating cardiologist recommended a neurology consultation, indicating a low likelihood that the patients symptoms are vascular. In sum, an evaluation by a neurologist is medically necessary given the patients symptoms that are suggestive of neuropathy. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested rhinoplasty surgery for treatment of her nasal obstruction.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The reviewed records indicate the patient has nasal valve collapse causing obstruction to airflow, 7mm anterior septal perforation with surrounding mucosal irritation and a saddle nose deformity.  The symptoms of nasal septal perforation include crusting, bleeding, whistling, and nasal airway obstruction due to disruption of the normal laminar airflow through the nasal passages.  Symptom severity is related to the size and location of the perforation, with larger anterior or caudal septal perforations being more problematic.  The findings of excoriated mucosa and bleeding associated with the perforation make its repair medically necessary.  Nasal airway obstruction can be due to septal deviation, enlarged turbinates, engorged or hypertrophic nasal mucosa, masses within the nose or external or internal nasal valve collapse. The fact that airflow improved with a Cottle maneuver suggests that surgical resolution of the valve collapse would treat the obstruction to nasal airflow.  All told, the requested rhinoplasty is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Standard Review The parent of a transgender male enrollee has requested authorization and coverage for consultation with a plastic surgeon regarding a bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees gender dysphoria.  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. Nature of Statutory Criteria/Case Summary: There is sufficient support in the documentation and in the medical literature for the requested services in this clinical setting. The surgical concept of treating female-to-male reassignment surgery is well established and documented within the medical literature. However, each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patients case, medical necessity has been adequately defined in the clinical documentation provided. The patient has identified as a male for an extended time and has been undergoing early steps towards his transition from female to male. He has also been seeing a therapist for 5 years. He has well documented gender dysphoria, and his dysphoria has affected his function. The request is for a surgical consultation and not for the actual surgery. This consultation should be considered medically necessary as the next step in this patient's treatment and consideration for further transition. As such, a plastic surgeon can adequately examine and evaluate the patient to determine the appropriateness of possible surgical treatment. While consideration should be given to all conservative measures for treatment prior to any surgical treatment options, the request for a surgical consultation should be considered medically necessary. For these reasons, an office consultation with a plastic surgeon regarding a bilateral mastectomy is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for continued acupuncture treatments for treatment of her chronic pain syndrome (thoracotomy syndrome). Findings:  The physician reviewer found that there is no other documentation regarding the effectiveness of any other acupuncture treatments received. The article cited above regarding treatment for complex regional pain syndrome indicates that acupuncture is not recommended for treatment based on 2 randomized controlled trials. It found there was no difference in analgesia in acupuncture-treated patients versus sham-treated patients. Based on current standards of practice and without any documented benefit in this patients case, the use of acupuncture as a long-term treatment/management option for patients with chronic pain is not indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for general anesthesia for the proposed dental procedures. The recent guidelines state that, at least two people with specific training and credentials should be present with a pediatric patient undergoing deep sedation or general anesthesia for dental treatment in a dental facility or hospital. The authors noted that, the sedation should be administered by a qualified anesthesia provider. In this case, the patient does not have a diagnosis of situation anxiety disorder in her medical records, nor is there evidence of any other behavior condition, which would make her cooperation during the procedure difficult. However, her dental provider has stated that the patient will need to undergo extensive restoration with tooth extractions and root canal procedures. These procedures will require general anesthesia to be provided by qualified anesthesia provider who is not performing the primary dental procedures. Based on the available records for review and the most recent guidelines, the requested general anesthesia for the proposed dental procedures is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 requested breast surgery for treatment of her bilateral ruptured silicone breast implants.  Findings:  The physician reviewer found that the medical literature reported that complications that arise from this surgery are well documented to include implant rupture and capsular contracture.  According to the medical literature It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation.  In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. The medical literature reported that capsular contracture is the most common and severe complication associated with silicone breast implants. She is not documented to complain of significant pain or have evidence of implant infection. Based on the entirety of the medical record, the patient had original augmentation mammoplasty for aesthetic concerns, and experienced a known complication in which her implants were replaced. A ruptured silicone implants can be considered an abnormal, however there is no evidence that there was trauma, infection, tumors, disease, congenital defects, developmental abnormalities to suggest an etiology of the implant rupture. In addition, there is no evidence that the patient has a functional deficit related to her implants. There is no evidence that the initial surgery was performed for reconstructive reasons. The surgery was performed to correct previous aesthetic intervention.  This implies a baseline relatively normal appearance. Thus, the surgery performed was for returning to an improved appearance relative to normalcy. Therefore, the surgery at issue does not meet the reconstructive surgery criteria. Final Result: The reviewer determined that the surgery at issue was not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for fluoroscopic guided left hip injection with Synvisc One. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials pertaining to osteoarthritis of the knees indicate that although viscosupplementation may relieve pain in some patients with osteoarthritis, it remains unknown who will benefit. Additionally, viscosupplementation can provide improvement in patients with osteoarthritis of the hip, although the evidence is limited. In light of the foregoing, viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is known benefit from prior injections, and the remaining treatment options are limited, with the alternative being a complex total hip arthroplasty. As such, the requested fluoroscopic guided left hip injection with Synvisc One is medically necessary for treatment of osteoarthritis of the patients left hip.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: Upheld

A 50-year-old female enrollee has requested Botox injections for treatment of her chronic low back pain.  Findings:  The physician reviewer found that in the medical literature, there is some evidence that Botox A can alleviate large muscle dystonia and spasm. Pharmacologically, this makes sense as Botox is an effective muscle dennervator through its role of Acetylcholine blockade at the neuromuscular junction. With numerous studies in support of its safety and efficacy, the Food and Drug Administration (FDA) has approved Botox in the treatment of a number of well defined dystonias and small muscle conditions. However, only a small cohort of studies with questionable methodology, and small sample sizes are available for review for chronic low back pain. As such, there is limited evidence that Botox is more effective than lidocaine or Marcaine for low back trigger point and myofascial conditions. This patient presents with low back pain attributed to post-laminectomy syndrome and continued significant lumbar facet arthrosis, spinal stenosis and degenerative disc disease.  The records do not mention treatment with facet blocks or dorsal medial branch blocks. Further, the provider does not discuss consideration of medial branch rhizotomy, which in appropriate situations and with improving technology can provide up to 1-2 years of effective relief. As recommended by Jabbari, Botulinum toxin-A should be considered for treatment of low back pain when other modes of treatment fail to improve pain. Since this patient has not failed all other minimally invasive interventional therapies, the requested treatment with Botox is not clinically warranted at this time (Kamanli, et al). For these reasons, the patient should continue to be treated with more conventional modalities with better evidenced based support for management of chronic axial back pain prior to resorting to Botox, which is not medically necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

An 80-year-old male enrollee has requested for brand name Xalatan for treatment of his narrow angle glaucoma.  Findings:  The physician reviewer found that one pilot study compared generic and brand name medications in a small number of patients however the results were not statistically significant (Narayanaswamy, et al). In addition, there is reliable evidence in the medical literature that generic compounds of drugs are equivalent to their brand name counterparts (Kesselheim, et al). Based on these data, Xalatan and Latanoprost should be considered equally effective and safe for the treatment of this patients glaucoma. Therefore, the requested name brand Xalatan has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a colonoscopy. The submitted documentation supports the requested services in this patients case. Although not routinely recommended for the evaluation of constipation, the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that colonoscopy may be done once to rule out disease, especially if symptoms are unresponsive to therapy, as in this case. ASGE guidelines for the evaluation of constipation state that colonoscopy should be considered in selected patients to exclude obstruction from cancer, stricture, and extrinsic compression. Colonoscopy is useful to assess for organic causes of constipation.  This would be useful in this clinical setting, as laxatives at a normal dose have been ineffective. Therefore, the requested colonoscopy is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 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.