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 Xeljanz 5 mg tablet daily. Findings:  The physician reviewer found that the most recent published guidelines, the treatment of alopecia areata includes methotrexate and contact sensitization. Few treatment methods have been evaluated by randomized control trials to determine the most efficacious modalities to treat alopecia areata. While the Janus kinase (JAK) inhibitors, such as Xeljanz, show excellent promise in treating extensive alopecia, there is a paucity of peer-reviewed medical literature showing that Xeljanz is superior to standard therapies. According to the Alopecia Areata Consensus of Experts, there is agreement on the effectiveness of monotherapy with oral corticosteroids, cyclosporine, and JAK inhibition therapy as well as combination therapy of oral corticosteroids together with cyclosporine or methotrexate when used as steroid-sparing agents. This patients records document alopecia areata that has failed to improve with steroids. However, there is a lack of evidence that the patient has failed standard therapies to support an indication for treatment with Xeljanz. There is a lack of data that Xeljanz is likely to be more effective and well-tolerated as compared to standard treatments like methotrexate, cyclosporine or contact sensitization. Therefore, the requested Xeljanz 5 mg tablet daily is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Xeljanz 5 mg tablet daily 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 likely to be more beneficial for treatment 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 dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old male enrollee has requested chemotherapy using Vectibix, Erbitux and irinotecan for the treatment of his metastatic lung cancer. Findings:  Two physician reviewers found that this patient has tried and eventually progressed on several different chemotherapeutic regimens. The patient had a pronounced response to Tarceva, which, as his physician states, is indicative that the tumor is very sensitive to endothelial growth factor receptor (EGFR) inhibition. There is support for the use of EGFR inhibitors (including the monoclonal antibody Erbitux). Butts and colleagues demonstrated benefit from the addition of Erbitux to a chemotherapeutic regimen for patients with advanced localized or metastatic non-small cell lung cancer (NSCLC). In addition, the study by Hanna and colleagues involved patients who had prior treatments for their NSCLC, with 57% of the patients having two or more prior regimens. No patient had a complete response, but stable disease was achieved in 30% of the patients studied.  Irinotecan has been shown to be efficacious in the treatment of advanced and metastatic NSCLC, both alone and in conjunction with other medications. It has not previously been used in this patient, and the patient has not been treated with any medications with a similar mechanism of action. There is currently no data that supports the use of Vectibix, alone or in combination with the other requested medications, for the treatment of NSCLC. Given the patient's pronounced response in the past to Tarceva and the progression on his recent regimen, Erbitux and irinotecan are more likely to be beneficial for the patient than other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested therapy for treatment of his neck and back pain. Findings:  Two physician reviewers found that the medical notes state that the patient received facet joints and/or trigger point injections. The descriptions do not illustrate that the patient underwent injections of the facet joints.  While areas around the facet joints were marked, the notes do not describe if the injections in fact entered the facet joints or if medial branch or facet joint nerve blocks were performed. Thus, it appears that these injections were trigger points or infiltration around the facet joints rather than intraarticular or medial branch blocks. The services performed are consistent with trigger point or ligament injections. Such treatment is within the standard of care in this setting. Considering the patient has neck and low back pain, ligament or trigger point injections were indicated and were likely to be more efficacious than alternative treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  Two physician reviewers found that the report noted a positive family history of breast cancer and calculated lifetime risk of the disease of 20.9%. The study revealed no evidence of malignancy.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis on 8/3/16 to the usual two dimensional protocol was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone. Final Result: Two reviewers determined that the service at issue was 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old female with a weight of 396 pounds and a body mass index (BMI) of 58.6 in August 2005. She is requesting authorization for bariatric surgery. She reports comorbid conditions included hypertension, osteoarthritis, insulin dependent diabetes and gastroesophageal reflux disease. She has completed a psychological evaluation and was found to be an appropriate candidate for bariatric surgery.  The Health Plan indicates a 10% weight loss requirement is a prerequisite to approval for weight loss surgery. With a BMI of 58.6 and comorbid conditions such as diabetes, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees substance use disorder.  Findings:  The physician reviewer found that this was a young, healthy, man who had been sober for two weeks prior to this admission. The patient had no other treatment interventions, and reported no physical or mental conditions that would distract him from treatment. He participated in treatment three times per week for almost nine months and was noted to be good at helping others. In this patients case, the current American Society of Addiction Medicine (ASAM) placement criteria support an outpatient level of care. The records indicate the patient was not at imminent risk for withdrawal and he was a relapse risk commensurate with his state of recovery. Thus, the patient did not need the structure of an IOP to enforce relapse prevention. Further, the patient had good engagement in treatment and was aware of the substance use problem. All told, the patient did not require a structured program several times a week to promote progress through the stages of change. The records indicate the patient could have been safely and adequately treated on a routine outpatient basis and the IOP services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested cerebral perfusion imaging for medical evaluation of the enrollees cerebrovascular accident (CVA). Findings:  Two physician reviewers found that while the role of perfusion imaging has been established for acute neurologic event, it has been less regarded in terms of the role in chronic ischemia, as in this case. The American College of Radiology (ACR) lists primary and secondary roles of CT perfusion imaging which suggest the role in this patient would be a secondary indication, not a primary indication. Although perfusion imaging may be able to differentiate at risk tissue, it has not yet been shown in peer-reviewed medical literature, to affect outcome outside of acute ischemia. Therefore, cerebral perfusion imaging is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Advair Diskus Aero Pow BR Act 100-50 mcg. Based on the available information, this patient presents with poorly controlled asthma. The provider charted that while on generic Advair, the patients symptoms worsened, which supports treatment with brand name Advair. The U.S. Food and Drug Administration (FDA) has approved Advair Diskus Aero Pow BR Act for the treatment of patients with asthma. Moreover, the Global Initiative for Asthma (GINA) supports treatment with Advair Diskus Aero Pow BR Act for the treatment of this patients asthma given her prior positive symptomatic response with this therapy and return of symptoms with generic Advair.  Therefore,  the requested Advair Diskus Aero Pow BR Act 100-50 mcg is medically  necessary  for treatment of 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 internal medicine with subspecialty certifications in pulmonary disease and critical care 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda 18 mg/3 mL pen injector. Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist that, in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating. It is labeled as an adjunct to diet and exercise for weight management in overweight or obese adults. This medication is recommended for patients that have features of the metabolic syndrome or insulin resistance syndrome, which this patient has. Hyperlipidemia and hypertension can be improved with weight loss. Researchers performed a study on obese/overweight individuals who lost at least 5% of initial weight during a low-calorie diet. The individuals were randomly assigned to liraglutide 3.0 mg per day or placebo for 56 weeks. The authors noted, Liraglutide, with diet and exercise, maintained weight loss achieved by caloric restriction and induced further weight loss over 56 weeks. Improvements in some cardiovascular disease-risk factors were also observed. Researchers performed a study on adults with a BMI from 30 to 40. The authors noted, Liraglutide is well tolerated, sustains weight loss over two years and improves cardiovascular risk factors. In this patients case, phentermine is not recommended due to hypertension. Given the patients BMI of 29.4 kg/m2 with comorbidities of hypertension and hyperlipidemia, the requested medication is medically indicated. Therefore, Saxenda 18 mg/3 mL pen injector 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the FoundationOne blood test. Chordomas are bone tumors that are locally invasive, frequently recur, and are relatively radioresistant. Systemic therapy for the treatment of relapse after maximal surgery and/or radiation therapy has focused on molecularly targeted therapies. This patient has exhausted standard molecularly targeted therapies known to effective for chordoma. Several signal transduction pathways including platelet-derived growth factor receptor, epidermal growth factor receptor, and mammalian target of rapamycin have been implicated in the pathogenesis of chordomas, leading to the development of targeted therapies. The National Comprehensive Cancer Network (NCCN) indicates that the best management of any patient with cancer is in a clinical trial. Moreover, molecular profiling can identify mutations which may enable a patient to enroll on a clinical trial. All told, the FoundationOne blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the FoundationOne blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  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

A 48-year-old female enrollee has requested a consultation with a bariatric surgeon for the treatment of the enrollees obesity. Findings:  The physician reviewer found that this patient has obesity-related comorbidities that will be ameliorated or eliminated by bariatric surgery. She is requesting a lap band which requires far more compliance than gastric bypass.  Although she has listed the diets which she tried and failed, we do not have dates, length of success, and degree of physician supervision. Gastric banding requires an understanding of the eating behaviors that will lead to failure. The patient carries a diagnosis of depression, yet the submitted documentation does not include a psychiatric evaluation or evidence that she is being treated. This patient would benefit from a multidisciplinary approach, including physician supervised diet, behavioral counseling, and attendance at support groups. The requested service is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female has requested anesthesia services during a colonoscopy.  Findings:  The physician reviewer found that the patient has a history of Crohns disease and per the submitted documentation, she is status post resection of the small intestine and removal of appendix.  Her most recent colonoscopy was six years ago.  The patients provider has recommended a colonoscopy.  Per the provider, the patients previous colonoscopies have all been performed with anesthesiology assistance.  The American Society of Anesthesiologists position statement notes that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication, with or without analgesia, to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must continuously monitor the patient.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients who are younger than 12 years of age, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this patients case, the submitted documentation indicates that the patient has no specific medical comorbidity that necessitates the use of monitored anesthesia care for the recommended colonoscopy.  This patient is an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 45-year-old male with two level degenerative disc disease at L4-5 and L5-S1, confirmed by MRI and discogram.  It has been recommended that he undergo percutaneous lumbar disc annuloplasty using the IDET technique.  The Health Plan considers the procedure experimental and therefore, has denied authorization.The proposed procedure is experimental at this time.  There is no class I data to support the use of percutaneous lumbar annuloplasty for the treatment of multi-level lumbar degenerative disc disease.  The outcomes for this interventional procedure, like many similar techniques for degenerative disc disease, are historically poor. This patient should be treated conservatively with physical therapy, anti-inflammatories, and other non-interventional measures.  Because the proposed annuloplasty is not of established efficacy, I have determined that it is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 45-year-old male with back pain that interferes with his work and routine daily activities.  He has tried some conservative treatments without measurable success.  It has been recommended to him that he undergo percutaneous lumbar disc annuloplasty utilizing the IDET technique. The Health Plan has not authorized the procedure based on its experimental/investigational status.The requested procedure has not been proven effective in any long-term prospective studies, and it is therefore experimental/investigational.  It is noted in this particular case, the likelihood of success is only about 50%.  This is not an acceptable risk for a procedure with limited documentation of its reliability.  The patient is likely to achieve superior results from standard treatment modalities. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient has a history of chronic low back pain. He has attempted conservative therapy including medications and physical therapy without lasting benefit. He has undergone a discogram that was positive at multiple levels. He is now requesting authorization for percutaneous lumbar disc annuloplasty using the IDET technique.All evidence regarding percutaneous lumbar disc annuloplasty is either non-controlled or non-prospective. The proposed procedure does not have proven long-term efficacy. Complicating this case is the patients multilevel positive discography. Given these results, it is highly unlikely that percutaneous lumbar disc annuloplasty will provide the patient any benefit. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.