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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper airway stimulation device (outpatient surgery). Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy for treatment of OSA. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Researchers found that hypoglossal nerve stimulation can provide significant improvements in objective and subjective measurements of the severity of OSA. Given this patients BMI of 26, AHI of 20.6, nonconcentric airway collapse, and failure of CPAP, the requested upper airway stimulation device (outpatient surgery) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested upper airway stimulation device (outpatient surgery) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested upper airway stimulation device (outpatient surgery) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen 10 mg-325 mg, 100 tablets per 30 days. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the patients pain. The submitted documentation does not support the medical necessity of the requested medication. Clinical practice guidelines do not support the use of opiates for chronic pain. While the use of opiates may be helpful in the acute setting, chronic use of opiates has been associated with limited efficacy and may lead to dependency and abuse. There are multiple alternatives without these risks. There is a lack of support for the requested medication in this clinical setting. Therefore, hydrocodone-acetaminophen 10 mg-325 mg, 100 tablets per 30 days are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty 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

A 52-year-old male enrollee has requested for Celebrex for treatment of his prostate cancer. Findings:  The physician reviewer found that there are a few research studies suggesting that COX II inhibitors may slow the progression of prostate cancer on a theoretical basis, but there is a true paucity of data of any kind with respect to actual clinical trials. One clinical trial was terminated early due to concerns raised about COX II inhibitors and cardiovascular safety of the drugs. Additional studies are needed before use of Celebrex for this patients condition would fall under standard of care
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 16-year-old male enrollee has requested for Vyvanse for treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).   Findings:  Two physician reviewers found that the patient has a confirmed diagnosis of ADHD and responded favorably to treatment with Vyvanse, 70 mg per day. Vyvanse is approved by the FDA for the treatment of ADHD. That approval was based upon a clinical trial with children from six to 12 years of age. FDA approval, among other things, limits the marketing claims a drug manufacturer may make. Practitioners may prescribe a medication for indications that are not specifically stated in the product label and may likewise prescribe a product outside the age range in which the product was studied. The age difference in this instance does not appear to be clinically significant. Treatment with Vyvanse, 70 mg daily, is clinically indicated for treatment of the patients ADHD. He has not had a satisfactory response to other medications and, most importantly, he is currently benefiting from this treatment. To convert him to formulary drug at this juncture would be medically inappropriate and create an unnecessary medical risk, which is never in the patients best interest.
Appeal type: Experimental/Investigational
Decision: Upheld

47-year-old female enrollee requested infusion medication (ceftriaxone) for treatment of her medical condition.  Findings:  Three physician reviewers found that the patient does not present with a diagnosis of neuroborreliosis, Lyme arthritis or cardiac complications of Lyme disease. There are no physical exam findings, laboratory or imaging results that indicate the diagnosis of Lyme disease. The symptoms and MRI findings are non-specific and do not demonstrate Lyme disease. Moreover, the treatment of Lyme disease is a three-week course of intravenous antibiotics. Longer or repeat courses have not been shown to be efficacious in the treatment of Lyme disease. Thus, infusion medication with ceftriaxone was not and is not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks. 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 non-cirrhotic genotype 1 patients who have failed PEG-interferon/ribavirin and triple therapy should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, based on clinical trials in this population . In genotype 1a patients without NS5A resistance, as in this case, Zepatier for 12 weeks is appropriate. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. No medical contraindication to Zepatier is reported in this case. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni 90-400 mg tablets for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection given the availability of Zepatier. 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 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: Upheld

A 54-year-old female enrollee has requested a Dynasplint brace for the treatment of her hallux limitus. Findings:  Three physician reviewers found that there is little evidence in the literature of the use of dynamic splinting devices, such as the Dynasplint, in the treatment of problems, such as is the case with this patient. There are some anecdotal reports of successful results, but a paucity of controlled studies. Some studies are in progress, but until they are completed, evaluated and reported, the use of the Dynasplint remains investigational in nature for this patients diagnosis. Therefore, the denial was medically appropriate.
Appeal type: Urgent Care
Decision: Overturned

The parent of a three-year-old male enrollee has requested emergency services for treatment of the enrollee's fever.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patients symptoms met prudent layperson criteria for emergency care. The patient presented with acute symptoms of pain, lethargy and fever which were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in jeopardy due to the risk of serious and life threatening infection such as meningitis. Given the lack of adequate response to treatments administered at home, it was reasonable for the patients parents to seek immediate medical attention on the date of service in question.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a power operated vehicle (POV for treatment of the enrollees idiopathic aseptic necrosis of head and neck of femur.  Findings: The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. The documentation submitted for review does not demonstrate that the patient is unable to safely use a manual wheelchair or other walking aid such as a walker, crutches or cane. In addition, the documentation submitted for review does not reveal a thorough gait assessment. There are no physical therapy documents evaluating the patients gait or ability to use a manual wheelchair or other walking aid. Moreover, there is no clear physician evaluation of the upper extremities that specifically examine range of motion, strength, deformity, endurance or coordination or objective documentation on physical examination or electro diagnostic testing of carpal tunnel syndrome that would reveal that the patient has deficiencies in the upper extremities that would prohibit a manually operated device. There is also no evidence that a modification to a manual wheelchair hand rim was attempted that would enable the patient to safely operate a manual wheelchair. For the aforementioned reasons, the request for a power operated vehicle is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 46-year-old female enrollee has requested esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of her peptic ulcer disease and multiple polyps. Findings:  The physician reviewer found that in the medical literature, Mekaroonkamol and colleagues evaluated the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer screening or surveillance. The authors concluded that only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management. Loyd and McClellan noted that warning signs of serious disease, such as cancer, or unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, and a family history of cancer. In these cases, more extensive laboratory investigation, imaging, and endoscopy should be considered as clinically indicated. This patients symptoms may best be characterized as functional dyspepsia. As this patient has symptoms refractory to empiric treatment, sign of gastrointestinal hemorrhage, and family history of gastrointestinal cancer, the requested repeat upper endoscopy and colonoscopy are supported as medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for voice therapy, including office visit; laryngoscopy telescopic; speech/hearing therapy; laryngeal function studies; and behavioral and qualitative analysis of voice and resonance are medically necessary for treatment of this patient. For transgender females, voice therapy is an important component of treatment to aid in gender transition. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further supports the incorporation of voice therapy to address a patients gender dysphoria and noted that the discrepancy between outward gender presentation and the felt sense of gender is not trivial; it can impair confidence in communication, comfort with gender presentation, and function in the everyday world. The WPATH SOC recommends voice and communication therapy to help alleviate gender dysphoria and be a positive and motivating step towards achieving ones goals for gender role expression. This patients records demonstrate a history of gender dysphoria. The patients providers have documented that she is misgendered due to the masculine tone of her voice. Given these findings, the requested voice therapy, including office visit; laryngoscopy telescopic; speech/hearing therapy; laryngeal function studies; and behavioral and qualitative analysis of voice and resonance are 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Botox treatment performed on 8/12/15 and 1/13/16. Findings:  Two physician reviewers found that chronic exertional compartment syndrome is defined as reversible ischemia that is unresponsive to the expansion of muscle volume that occurs with exercise. Chronic exertional compartment syndrome is distinct from functional popliteal artery entrapment which refers to intermittent arterial compression. Compartment syndrome in the leg is most common in the anterior and lateral compartments and least common in the posterior compartments where this patients injections were performed. There is a lack of studies comparing Botox to standard surgical treatment for either chronic exertional compartment syndrome or functional popliteal artery entrapment. In this case, the providers notes indicate that after the initial 8/12/15 injection the patients symptoms returned and he was retreated on 1/13/16, and the patients symptoms returned again. Final Result: Two reviewers determined that the services at issue were 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: Two physician reviewers are board certified in orthopedic surgery and is actively practicing. One physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keytruda 200 mg injection every three weeks. For the treatment of recurrent meningiomas, Keytruda is not FDA approved or supported by major drug compendia. However, the medical literature supports use of Keytruda in patients with increased programmed death-ligand 1 (PD-L1) expression, high mutational tumor burden, high frequency MSI, or mismatch repair (MMR) deficiency on sequencing that may increase the likelihood of responsiveness to immunotherapy. This patients tumor does not meet any of these criteria to indicate a likely response. Therefore, the requested Keytruda 200 mg injection every three weeks is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Keytruda 200 mg injection every three weeks is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 1 is board certified in board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in board certified in internal medicine with subspecialty certification in medical oncology and is 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 57-year-old female enrollee has requested acute inpatient treatment for treatment of her bipolar disorder, type I, with severe depression.  Findings:  The physician reviewer found that per the American Psychiatric Association, criteria that may necessitate an inpatient level of care for an individual with bipolar disorder include when the individual poses a serious threat of harm to themselves or others, when the individual is severely ill and lacks adequate social support outside a hospital setting or demonstrates significantly impaired judgment, when the individual has complicating psychiatric or general medical conditions, or when the individual has not responded adequately to outpatient treatment. This patient meets all of the above criteria for a continued stay in the hospital for approximately three weeks.  After the third week, she could have been discharged to a partial hospitalization program. Thus, acute inpatient treatment for three weeks was medically indicated for this patient. After the third week and forward, partial hospitalization was and is medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and Daklinza for 12 weeks 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, and patients with cirrhosis are high priority for therapy. Per the guidelines, non-cirrhotic treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. This recommendation is based on multiple randomized clinical trials, and the guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients (Zeuzem, et al; Lawitz, et al; Jacobson, et al). According to the guidelines, Sovaldi and Daklinza should only be used when there is a medical contraindication to ribavirin. While treatment of this patients hepatitis C is medically necessary, there is no documentation to show that he has a contraindication to ribavirin. For these reasons, treatment with Sovaldi and Daklinza for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualification:  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: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a custom fabricated right knee brace. Steadman and colleagues note that there is clinical evidence supporting brace use as improving pain and functional ability in patients with unicompartmental knee osteoarthritis. In a meta-analysis of randomized trials involving valgus bracing for knee osteoarthritis, Moyer and colleagues did not note a significant difference between custom and off-the-shelf bracing. In this case, given that the submitted records do not document a trial of off-the-shelf bracing, the requested custom brace is not medically indicated. Therefore, a custom fabricated right knee brace is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested a percutaneous disc decompression (PDD) procedure for the treatment of her back pain. Findings:  Three physician reviewers found that the requested procedure does not appear to be indicated in this case. The MRI study does not reveal a large right or left side disc herniation, and the patient does not appear to have radicular complaints. The patients chronic pain is not an indication for surgery. Furthermore, there is no evidence demonstrating that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than other available procedures.