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

A 29-year-old female enrollee has requested Alinia for the treatment of her toxoplasma gondii and bacterial overgrowth. Findings:  The physician reviewer found that Alinia was prescribed in this case to treat toxoplasma positive serology (toxoplasma gondii) and bacterial overgrowth as indicated by the provider. A review of the peer-reviewed scientific literature revealed no evidence supporting the use of Alinia for treatment of these conditions. Alinia is not approved for either diagnosis and there are more standard alternatives. Moreover, positive toxoplasma serology without laboratory confirmation is not sufficient to confirm a diagnosis of toxoplasmosis. The symptoms described are not those of toxoplasma, nor do the patients history and labs support such diagnosis. There is no confirmatory evidence to support toxoplasma positive serology and bacterial overgrowth. Even if these conditions were present, they are not indications for Alinia treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male has requested participation in Phase III Clinical Trial Evaluating DCVax-L, Autologous Dendritic Cells Pulsed with Tumor Lysate Antigen for the Treatment of Glioblastoma Multiforme.  Findings:  The  physician reviewer found that chemotherapy prolongs survival with modest gains in some patients with GBM. The standard of care is to resect the GBM maximally followed by treatment with temozolomide. The regimen of temozolomide treatment concomitant with radiation therapy was analyzed in a randomized clinical trial setting with 26.5% two-year survival, compared to 10.4% in the cohort receiving only radiation (Taphoorn, et al; Stupp, et al). Most GBM tumors recur and then the treatment options are limited. According to the Physicians Data Query, patients who have brain tumors that are either infrequently curable or unresectable should be considered candidates for clinical trials. Further, dendritic cell vaccination therapy is listed as a potential clinical protocol under the available treatment options (Fecci, et al; Luptrawan, et al). There are two major advantages to this patient receiving the next step of his treatment at UCLA. First, the facility is a National Cancer Institute (NCI) designated cancer center, where multidisciplinary care is readily available. Second, the surgery will enable him to enroll in a phase III clinical trial. The Health Plans providers agree that repeat resection is required. In addition, the literature indicates that patients with poor prognosis should have reasonable access to a reasonable clinical trial as part of the standard of care for treatment of cancer patients. All told, the requested services including participation in the Phase III Clinical Trial Evaluating DCVax-L, Autologous Dendritic Cells Pulsed with Tumor Lysate Antigen for the Treatment of Glioblastoma Multiforme are supported as medically necessary in treating this patients medical condition and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. 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. This applies regardless of fibrosis stage or viral load. 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 guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is 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 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

A 27-year-old female enrollee has requested an occipital nerve stimulator trial for treatment of her occipital neuralgia. Findings:  The physician reviewer found that the facts probative of the medical necessity of the requested device for this patient include the severity and refractory nature of the headaches, her young age, the duration of symptoms, and disability due to the condition. At only 27-years of age, this patient has an 8-year history of refractory and severely disabling headaches that have completely interfered with her quality of life. She has had a comprehensive multimodal approach to therapy, with physical and medical therapies, interventional and conservative management attempts, that have failed to produce any long-term results. She responds very well to occipital nerve blocks, but this treatment only lasts about two months. Therefore, this patient would benefit from at least a trial of ONS with temporary leads. If the patient responds well with significant reduction in headache frequency and severity, then the permanent implant would be appropriate. Given this patients severe and frequent refractory headaches, an ONS trial is both necessary and justified based on an evidence-based review of the case, the applicable standards of care and relevant medical literature.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested for direct voice rehabilitation for treatment of his spasmodic dysphonia.  Findings:  The physician reviewer found that the scientific data is replete with studies regarding the use of botulinum toxin (Botox) for this condition and it is well-accepted that this is the most commonly used treatment. In addition, there are published results demonstrating the positive outcomes in patients who have undergone surgical repair, although these studies involve small numbers of patients studied. All told, while there are limited options in this setting, there is greater support for the efficacy of Botox and surgical intervention than direct voice rehabilitation, which has not been the subject of peer-reviewed studies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for trigger point injections. In the medical literature, Gerwin noted that myofascial pain syndromes caused by trigger points in muscle are a common cause of local and generalized pain. However, the authors concluded that there is a lack of adequate studies to support the use of trigger point injections in the treatment of patients with nonspecific low back pain. Urits and colleagues described myofascial pain syndrome (MPS) as a regional pain disorder that is characterized by the presence of trigger points (TrPs) within muscles or fasciatypically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The authors discussed the available treatment options and reported that, More research is needed to form uniformly-accepted diagnostic criteria and treatments. In this case, the patient has a history of thoracic compression fracture of T7-8. The patient presents with complaints of low back pain radiating into the lower extremities. The patients physical examination of the spine was unremarkable without evidence of trigger points identified. The provider charted that the patients thoracic pain should be managed with an epidural steroid injection to treat suspected thoracic radiculopathy. Furthermore, there were no findings on physical examination of thoracic muscle trigger points consistent with a primary muscle spasm as the cause for the patients symptoms. The providers clinical documentation suggests that the underlying cause of the patients pain is thoracic radiculopathy. Thus, the requested trigger point injections are not indicated for treatment of this patient. For these reasons, the requested trigger point injections are not medically necessary for 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 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: Upheld

An enrollee has requested authorization and coverage for lidocaine 5% patches (30 patches for 30-day supply).The submitted documentation does not support that the requested medication is medically necessary in this clinical setting. The manufacturer label for Lidoderm includes the following general precaution for Hepatic Disease, `Patients with severe hepatic disease are at greater risk of developing toxic blood concentrations of lidocaine, because of their inability to metabolize lidocaine normally.` Lidoderm patches are indicated for the treatment of post herpetic neuralgia for localized pain and not for either generalized osteoarthritis or inflammatory erosive systemic arthritis. In this case, the patient has a systemic inflammatory form of arthritis for which Plaquenil has been prescribed as well as multiple intraarticular steroids. The patient also has a history of chronic hepatitis related to alcohol use. The provider is concerned about hepatic issues, and the patient is already using lidocaine 4% over-the-counter. Under these circumstances, the requested medication lidocaine 5% patches (30 patches for 30-day supply) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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

The parent of a 14-year-old female enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that the patient presented with signs and symptoms consistent with a variety of potentially serious diseases including sinusitis (especially given her past history of the diseases), meningitis, otitis media, and other infectious diseases.  It would be appropriate for a prudent layperson to seek immediate medical attention due to potential jeopardy to her daughters life and/or bodily organ functions.  Early cases of meningitis (a potentially life-threatening disease) often mimic general viral illnesses and present similarly to how the patient presented to the ED.  It was appropriate for the patients mother to bring her daughter in for an exam to rule out more serious disorders.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested  for Viagra for treatment of his erectile dysfunction (ED). Findings:  The physician reviewer found that there is also some evidence that Viagra may be helpful with psychogenic impotence. In any event, treatment with an oral PDE-5 inhibiting medication, Viagra, was initiated several years ago. This medication has apparently been an effective treatment for the patients ED. Regardless of the source of erectile dysfunction, Viagra is considered a first-line therapy. There are no contraindications to the medication based upon the information provided and the patient should continue to receive Viagra for appropriate management of his ED.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a deceased forty-three year-old female diagnosed with hepatitis B, cirrhosis, hepatocellular carcinoma is requesting reimbursement for emergency and acute inpatient care.  Reviewers Findings:The reviewing physician found that because of the seriousness of the patients condition the emergency and acute impatient care were medically necessary.   The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old woman with a history of abnormal bleeding. A sonogram revealed a thickened endometrium. An endometrial biopsy was normal. The patient was given Provera, and oral Prometrium to help control the bleeding. These apparently produced side effects. She was then given Crinone gel, which is a vaginal gel that contains progesterone. The Health Plan has denied authorization for Crinone gel indicating that it is not medically indicated because it is not being used to treat infertility or secondary amenorrhea.The use of Crinone gel is not medically necessary. Other tests should be performed to rule out possible causes for the patients abnormal bleeding. The patient did undergo a sonogram, which showed a thickened endometrium. However, the submitted information does not indicate whether the sonogram was performed premenstrually. A sonogram performed premenstrually can show a thickened endometrium. Thus, a repeat sonogram after the end of menses may be indicated. If the endometrium is still thick, a sonohysterogram can be performed to rule out the presence of polyps. In addition, a D & C and hysteroscopy with directed biopsies would be appropriate.If the results of these tests are negative, the use of birth control pills for a three to six month period is appropriate. Birth control pills are known to decrease the thickness of the endometrium, especially if taken continuously. Although the patient is concerned about her family history of breast cancer, the use of birth control pills for this short span of time would not pose a danger. Another possibility would be for the patient to receive gonadotropin releasing agonist hormones to produce amenorrhea. If the patient continues to experience abnormal bleeding after the abovementioned tests and treatments, Crinone gel may be indicated. However, based upon the submitted clinical information, Crinone gel is not medically indicated at this time.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for 30 excimer UVB laser phototherapy sessions. The enrollee has vitiligo. She has hypo-pigmented, non-scaly patches to her upper and lower eyelids, face, inner thighs, hips, trunk, arms, legs, and feet. Her physician reports a 75 percent improvement. Thirty additional sessions have been requested to achieve 100 percent clearance. A review of monochromatic excimer laser for vitiligo showed the excimer laser is effective in adults and children with vitiligo of all skin types; either as monotherapy or in combination with other established treatments. Researchers report the excimer laser has governmental approval for the treatment of psoriasis and vitiligo. Researchers indicate the treatment is generally well tolerated, with few adverse reactions.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a liver biopsy and a Quad CT scan for evaluation of her focal nodular hyperplasia of the liver.  Findings:  The physician reviewer found that focal nodular hyperplasia is a benign lesion of the liver that has no malignant potential. A liver biopsy is not indicated in this case as two imaging modalities (CT and MRI) described pathognomonic features of focal nodular hyperplasia (feeding arterial vessel and a central scar). Furthermore, the size of these benign lesions do not present a risk. Thus, a liver biopsy is not indicated based on the patients imaging results. The liver biopsy will not alter the management of this patients care. Moreover, a Quad CT scan is not indicated as the patient has already undergone CT and MRI imaging which has resulted in a diagnosis of focal nodular hyperplasia. The results of a Quad CT scan will not have clinical utility in the care and management of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene testing for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx-Melanoma gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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 dermatology 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 dermatology 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 dermatology 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 51-year-old female has requested anterior surgical approach for hip replacement surgery for treatment of her osteoarthritis of the right hip.  Findings:  The physician reviewer found that Hallert and colleagues evaluated 200 cases of unilateral hip replacement in a prospective study. The authors concluded that the technique was more demanding than other lateral approaches due to limited surgical exposure. Patients with morbid obesity, muscular patients, or patients with short femoral neck or acetabular protrusion are more difficult to manage with an anterior approach. Muller and colleagues noted that minimally invasive total hip arthroplasty has been successfully introduced in the past decade. A direct lateral approach continues to be used commonly because of the advantages in visualization. The authors indicated that in the direct lateral approach fatty atrophy of the anterior third of the gluteus medius muscle may occur with reduced function, gait disorders, and pain. The authors concluded that no influence of the surgical approach could be observed in the gait patterns of their patients. The issue of the safest and best surgical approach for total hip arthroplasty has been an ongoing issue since the beginning of total joint replacement. There are basically four surgical approaches that over the years have been used for total hip replacement. The first would be the anterior Smith-Peterson approach using the interval between the tensor fascia lata and the sartorius muscle. The second is an anterolateral or Watson-Jones approach using the interval between the tensor fascia lata and the gluteus medius. The third is a lateral approach, which is discussed in one of the articles reviewed above where the gluteus minimus is detached and the gluteus medius is split. The posterior approach or Kocher-Langenbeck approach where the external rotators are taken down and the posterior capsule either excised or widely opened. These approaches have been part of the orthopedic methodology for many years being developed even before total joint arthroplasty. Although each of the approaches may be reasonable, the use of a specific approach depends upon the individual patient. In this specific case, there are no contraindications to an anterior approach. The fact that the anterior approach is facilitated by a customized operating room table or special retractors should not rule out the application of this technique when chosen by the operating surgeon.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old male with T1c adenocarcinoma of the prostate and a Gleason score of 3+3=6. He presented with minimal symptomatology and an initial PSA of 14. He sought multiple opinions from urologists, radiation oncologists, and medical oncologists. The patient was treated with two Lupron injections. His PSA decreased to 0.76 ng/ml. He wishes to undergo proton beam radiation therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.This patient with T1c prostate cancer received hormone therapy. His PSA has since dropped to 0.76 ng/ml. Review of the relevant medical evidence does not demonstrate a direct advantage of proton beam therapy over standard treatment modalities. The services offered by the Health Plan are medically reasonable and appropriate for treatment of the patients prostate cancer. There is no medical indication that proton beam therapy would be more beneficial in this patient than any available standard therapies. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.