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 Sutent. This patient has a uveal melanoma classified as high risk based on a class 2 genetic profiling. His uveal melanoma involves the choroid. At this time, no standard adjuvant treatment options have been established for use in this clinical setting. However, new data suggests that Sutent may provide benefit in uveal melanoma. A multi-institutional study of 128 patients of which 54 received Sutent showed a significant improvement with a statistically significant overall survival. Given the published peer-reviewed medical literature to support the use of Sutent, the requested Sutent 25 mg daily for 12 month is likely to be more beneficial than any available standard therapy for treatment of this patients medical condition. One reviewer found that Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: The patient has requested authorization and coverage for a transthoracic echocardiogram. To provide direction on the appropriate use of transthoracic echocardiogram, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published guidelines (Douglas, et al.; Fleisher, et al.). The ACCF and AHA guidelines state that transthoracic echocardiogram may be indicated for patients with dyspnea of unknown origin, heart failure with worsening dyspnea, changes in clinical status, or previously documented left ventricular dysfunction who have not undergone assessment within one year. Based on these recommendations, transthoracic echocardiogram for the evaluation of cardiac structure and function in patients with arrhythmias is indicated for frequent premature ventricular contractions or for sustained or non-sustained atrial fibrillation, supraventricular tachycardia or ventricular tachycardia. This patient had a benign first-degree AV block and is reportedly asymptomatic. Evaluation of this asymptomatic patients ventricular function with a transthoracic echocardiogram is not consistent with the current guidelines. Therefore, the requested transthoracic echocardiogram is not medically necessary for this patient. 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 internal medicine with subspecialty certification in cardiovascular disease 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 retroactive authorization and coverage and continuation of acupuncture services for treatment of the enrollees chronic pain. Findings: The physician reviewer found that there is sufficient support for a portion of the services at issue.  In reviewing the records available, it does not appear that the patient had an acupuncture trial prior to the services at issue. Given that the patient continued to be symptomatic despite medications, an acupuncture trial for pain management and function improvement was medically appropriate and is supported by the peer-reviewed literature.  The medical evidence supports the initial trial of acupuncture services. However, current guidelines support additional care based on the functional improvements obtained with the trial.  In this patients case, no significant functional improvement was documented with the trial.  Thus, the medical necessity of continued acupuncture services has not been established.  All told, acupuncture services were medically necessary, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in oriental 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services.  Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with worsening, persistent and localized abdominal pain. The patient reported pain with ambulation, a common presenting sign of peritonitis. The patients white blood cell count was elevated, prompting CT imaging to rule out acute infectious process. Diverticulitis without abscess was identified. Only after abscess was ruled out could the patient be safely released with appropriate antibiotics. The patients persistent, worsening abdominal pain is consistent with an emergency medical condition. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

A 48-year-old female enrollee has requested a duodenal switch procedure for the treatment of her obesity. Findings:  The physician reviewer found that there is no question that BPD-DS is appropriate, and even more so than other popular obesity procedures, such as banding and Roux-en-Y gastric bypass, in treating this enrollees obesity. There are many reasons cited in the literature that may have convinced the enrollee to be so committed to undergoing BPD-DS.  These include data from Hess et al that show the best long-term results for weight loss while ameliorating the highest percent of co-morbidities. Anthone also agrees with the above and states that patients ingest about 2/3 of their pre-op dietary intake without any specific food intolerance. Ninety-eight percent maintained normal albumin levels three years post-op. Vitamin B-12 deficiencies are less likely to occur and, if they do, they are much easier to treat. Patients do not show any clinical evidence of hypocalcemia or bone loss. Furthermore, Baltasar et al, along with the other authors, agree that where the pylorus is preserved dumping is almost non-existent; biliopancreatic reflux is prevented, which would improve the patients GERD; and vomiting is very rare.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Monitored Anesthesia Care (MAC). Findings:  The physician reviewer found that most lower endoscopy tests can be accomplished with no sedation, moderate sedation, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates work well for low-risk patients and procedures. The level of planned anesthesia determines who will be administering the sedation. Light or moderate sedation are usually administered by the gastroenterologist performing the procedure. Deep sedation and general anesthesia are administered by a nurse anesthetist or anesthesiologist. MAC is administered by an anesthesia professional who is in the room with the gastroenterologist and a nurse or technician. This is usually selected when there are concerns about the patients lungs, heart, or tolerance to midazolam or fentanyl. In this case, the patient has a past medical history of gastroesophageal reflux disease and hyperlipidemia. She has no evidence of significant cardiac or pulmonary comorbidity to substantiate the need for MAC during the colonoscopy. The American Society of Anesthesiologists (ASA) Score is a global score that assesses the physical status of patients before surgery. It is sometimes referred to as ASA-PS, because it is a measure of physical status. In scoring this patient, she is otherwise healthy, with only mild to moderate systemic medical conditions, and she is therefore classified as an ASA II patient. MAC is not medically indicated for ASA II patients. Accordingly, the Monitored Anesthesia Care (MAC) services at issue were not medically necessary for the patients medical condition.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 anesthesiology, with subspecialty 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: Overturned

The parent of a two-year-old male has requested coverage for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested speech therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, he demonstrates speech and language deficits that are negatively impacting his ability to communicate in a functional and age-appropriate manner.  The literature supports the medical necessity of speech therapy in this clinical setting.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested mental health inpatient treatment services for treatment of the enrollees depression and attention deficit disorder (ADD).  The physician reviewer found that the records indicate that this patient could have been safely discharged as he was no longer suicidal and had no homicidal thoughts or psychosis. In addition, the patient already had an outpatient psychotherapist who referred him to the hospital and he had a psychiatrist who was managing his medications. No significant changes were made to his medications while in the hospital. He was no longer a threat to himself or others and was not psychotic or having problems with performing activities of daily living. All told, the requested mental health inpatient treatment services were not medically necessary for treatment of this patients medical condition.  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 child and adolescent 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: An enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for 16 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. Findings: The physician reviewer found that according to the most recent joint 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that genotype 1a patients who have failed an NS5A inhibitor such as Harvoni should be re-treated with Mavyret for 16 weeks. These recommendations are based on the MAGELLAN-1 trial, which showed a 94% cure rate in this population.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablets for 16 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. hepatitis C infection. 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 Harvoni 90-400 mg for eight weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested radiofrequency treatment (radiofrequency neurolysis) of the neck for the treatment of her recurrent cervical facet pain radiating to the head and shoulders. Findings:  Two physician reviewers found that interventional procedures such as radiofrequency neurolysis have been described in the medical literature for purposes of diagnosis and treatment of cervical facet pain. They are indicated if conservative treatments have failed to provide adequate pain relief. Such is the case with this patient. Further, she reports that the radiofrequency treatment was very effective and lasted from four to six months. Radiofrequency neurolysis has allowed her to decrease her pain medications and increase her activity level. Based upon its demonstrated efficacy in this case, radiofrequency treatment (radiofrequency neurolysis) of the neck was and is medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81450).  Findings:  Two of the three physician reviewers found that chronic lymphocytic leukemia is characterized as an indolent leukemia, but a patients individual clinical course is not predictable. It is impacted by stage at presentation and certain biomarkers. Among these, mutations in TP53, NOTCH1, BIRC3, and SF3B1 have been shown to be helpful to categorize patients into prognostic groups. Thus, mutational analysis has been adopted by many oncologists at the time of chronic lymphocytic leukemia diagnosis. In addition to this indication, mutational analysis may also be needed in the case of treatment resistance. Many combinations of chemotherapies and newer agents have been shown to have a response in chronic lymphocytic leukemia, but none have clearly demonstrated an improvement in overall survival. Patients may exhibit resistance to therapy, and mutational analysis may be needed. This is particularly important for patients who have progressed on standard regimens. Alternatively, even U.S. Food and Drug Administration (FDA) approved therapies may require knowledge of patients mutations. For example, venetoclax is a BH3 mimetic drug that inhibits the function of the anti-apoptotic BCL2 protein. It is approved in chronic lymphocytic leukemia that has TP53 deletion. It targets a whole new class of cancer-causing proteins, but chronic lymphocytic leukemia mutational analysis is required for its proper use. Therefore, the current medical evidence supports the services at issue in this clinical setting. Thus, genetic testing (CPT 81450) was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested Avastin injections in the eye for treatment of her cystoid macular degeneration of retina, progressive myopia, vitreous opacities, and cobblestone retinal degeneration. Findings:  Two physician reviewers found that there is a paucity of evidence in the peer-reviewed medical literature demonstrating that Avastin is more effective than standard therapies in the treatment of pseudophakic cystoid macular edema (Arevalo, et al). This is particularly true for a patient presenting with a visual acuity of 20/25. In addition, the records do not document that conventional treatments such as intravitreal corticosteroids were utilized. All told, the use of Avastin for the treatment of cystoid macular edema was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested complete and radical anterior cervical discectomy C4-5 and C5-6 with insertion of ProDisc artificial disc at C4-5 and C5-6 for treatment of her pain. Findings:  Three physician reviewers found that despite the fact that artificial discs have been implanted for almost 15 years, there is currently insufficient data to adequately assess the performance of total disc replacement. There is no evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and fewer adjacent segment degenerative problems. Total disc replacement has been associated with a significant number of reoperations, and the potential problems that may occur with longer follow-up have not been fully documented. Anterior cervical discectomy with fusion (ACDF) may be considered to be the gold standard for treatment of symptomatic degenerative disc disease within the cervical spine. There is a lack of truly blinded studies establishing the efficacy, and the results are short-term. In this patients case, complete and radical anterior cervical discectomy C4-5 and C5-6 with insertion of ProDisc artificial disc at C4-5 and C5-6 was not likely to be the most beneficial treatment for this patient.