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

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for air ambulance services. The enrollee had a history of end stage renal disease (ESRD) secondary to diabetes mellitus type II.  He was evaluated previously and was placed on the waiting list for an organ transplant.  After receiving notification the enrollee was transported via air ambulance to the hospital for a kidney transplant. The health plan denied coverage for the air ambulance services as not medically necessary.  Transplant is time sensitive in the patient accepting the kidney and prolonged time can lead to dysfunction in the kidney.  The record indicates the enrollee had to travel over 1900 miles to receive his transplant. The offer was not available to him at a closer center. Travel by car or by commercial airline would have led to an undue delay in arrival at the transplant program. The medical literature supports air ambulance transportation was medically necessary for the enrollees medical condition and circumstance. A study showed the longer the organ is kept waiting for transplant into the recipient patient, there is an increased risk for acute kidney injury and delayed graft function. Also, this kidney injury significantly compromises the longevity of the allograft (implanted kidney) for the recipient patient.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified surgeon with experience in transplant surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested testosterone pellet implants for treatment status post hysterectomy and bilateral salpingo-oophorectomy.   Findings:  Three physician reviewers found that in this patients case, the services at issue were not and are not likely to be of greater benefit than other treatment options.  She is status post hysterectomy and bilateral salpingo-oophorectomy and is on estrogen replacement therapy.  The submitted medical records do not support testosterone pellet implants in this clinical setting.  The documentation does not provide details regarding why the patient is on testosterone or indicate what prior evaluation was performed.  There is no documentation regarding other therapies discussed.  All told, the submitted records do not demonstrate the superior efficacy of testosterone pellet implants provided on the date indicated or future testosterone pellet implant placement.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services (CPT 00811). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines noted that, the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The ASGE states that sedation and anesthesia in gastrointestinal endoscopy can be performed with moderate sedation by the endoscopist. In this case, the patient underwent a colonoscopy for investigation of rectal bleeding. The records provided for review did not document any cardiac or pulmonary disease. There is no documentation of a history of substance abuse or of any prior history of difficulty with sedation or anesthesia. The provider assessed the patient with an ASA score of 2, which indicates a low likelihood of complications from anesthesia during the procedure. There is no indication that the patient had any risk factors making his airway difficult to manage. Based upon the medical records available for review and the most recent guidelines regarding sedation for gastrointestinal endoscopy procedures, MAC services (CPT 00811) were not medically necessary for this patient.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 management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee requested gastric bypass surgery for medical treatment of her obesity.  Findings:  The physician reviewer found that the requested gastric bypass surgery is not medically necessary for treatment of the patients medical condition.  The medical documentation provided for review does not demonstrate that she has tried and failed conservative, nonsurgical attempts at weight loss. She has also not been evaluated in a multidisciplinary bariatric surgery clinic. Therefore, in the absence of a bariatric surgery evaluation performed by a bariatric surgical program the request for gastric bypass surgery is not medically indicated at this time. For the reasons provided, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male has requested coverage for a wireless capsule endoscopy for evaluation of his medical condition.  Findings:  Two physician reviewers found that the patient is under evaluation for his iron deficiency anemia. The patient has a history of hypertension and alcohol use. Because of suspected gastrointestinal (GI) blood loss or malabsorption of iron, the patient underwent an esophagogastroduodenoscopy (EGD) with small bowel biopsies, which was essentially normal and did not identify a source of bleeding. A subsequent colonoscopy showed a normal colon and there was a punctuate erosion in the terminal ileum which showed non-specific inflammation. He also underwent an MRI, which was within normal limits. His most recent hemoglobin was 12.4 gm/dl. In this patients case, there are no symptoms of malabsorption or inflammatory bowel disease such as diarrhea, abdominal pain, or unintended weight loss and the patients MRI was normal. Thus, there is insufficient data to suggest irritable bowel disease (IBD) based on the data provided. There is no suspicion of a small bowel GI lesion of significance, such as a polyp or neoplasm, based on the provided documentation. Additionally, there is no objective evidence provided to substantiate a diagnosis of anemia in this patient.  In the absence of evidence of an accepted indication for wireless capsule endoscopy, the performance of this study is of speculative benefit and is not likely to be of clinical value.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene expression profiling and protein biomarkers for treatment of his prostate cancer. Findings:  Three physician reviewers found that prostate cancers natural progression covers a very broad spectrum and treatment choices are based on clinical risk stratification. Stratification utilized clinical stage of disease, baseline serum prostate specific antigen, the histologic grade group (Gleason score), and extent of involvement (including the number of biopsy cores containing cancer). The role in clinical management of molecular profiling is still under investigation. There is a lack of available prospective clinical trials evaluating their use in this setting. Active surveillance is defined as a postponement of immediate definitive therapy with curative intent treatment instituted if there is clinical evidence of disease progression.  Definitive therapy is considered radiation therapy or radical prostatectomy. Therefore, the role of molecular profiling for risk assessment is still considered investigational. Given the low risk clinical characteristics of the cancer, the utility of the gene expression profiling and protein biomarkers was not likely to have been superior to the other available treatment options for the evaluation of this enrollee.Final Result: The three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in internal medicine with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess 145 mcg capsules for treatment of the enrollees slow transit constipation. The documentation indicates that the use of an osmotic laxative (MiraLAX) has not been successful in this patient. The American Gastroenterological Association (AGA) medical position statement on constipation states that the first line of therapy should be an osmotic agent. If that first line fails then another type of laxative such as a stimulant laxative should be tried before attempting treatment with newer agents, such as Linzess or Amitiza. Additionally, the AGA position statement notes that these newer agents have more adverse effects. In this patients case, a stimulant laxative has not been documented.  Moreover, the studies have shown that both Amitiza and Linzess are effective, and a reason to use Linzess over Amitiza in this case has not been provided.  For these reasons, Linzess is not supported as medically necessary for the 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 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: The patient has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings: The records provided for review document that this patient has a history of hepatitis C virus, genotype 3. The provider has recommended treatment with Epclusa for 12 weeks based on the patients genotype and treatment naive status. According to 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 life expectancy less than 12 months due to non-liver-related conditions. The guidelines noted that these recommendations apply in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This recommendation is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines state that resistance testing is not supported, given the high efficacy of Epclusa. The guidelines further cite data showing reduced survival with delayed treatment. For these reasons, the requested Epclusa 400-100 mg tablets for 12 weeks are medically necessary for 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 subspecialty 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 OxyContin for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the medication at issue in this clinical setting.  The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the acute, chronic, or acute on chronic setting.  The records indicate that the WHO ladder for pain relief was followed in this case.  There is a lack of evidence to recommend one long-acting pure mu agonist opioid over another.  The medical records document that this patient experienced significant pain, and the current medical evidence supports the medication at issue in this patients case.  All told, OxyContin was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Prometheus Anser ADA Diagnostic Testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that in theory, this method of testing could allow for personalized care in which the drug level is optimized based on individual results.  However, in clinical practice, these tests fall far short.  Patients fail on a biologic for a number of reasons, including the presence of a surgical complication of disease.  In other cases, patients do not respond even with an optimized level as their disease is refractory to anti-tumor necrosis factor treatment.  Per the medical evidence, the testing at issue has not been shown to be superior to routine clinical care.  All told, Prometheus Anser ADA Diagnostic was not likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Overturned

A 48-year-old female has requested Herceptin 450mg every three weeks for treatment of metastatic breast cancer.  Findings:  The physician reviewer found that the continuation or re-starting of Herceptin in patients with a past history of treatment with Herceptin remains controversial. Several studies have examined this question, but data remains limited at this time. In this setting, many oncologists would initiate a combination of Xeloda with Tykerb (an oral drug that bears similarity to Herceptin in mode of action), but this patient was unable to tolerate this regimen. Prevailing opinion in the oncologic community would then be to add Herceptin to the patients new chemotherapy regimen. Thus, the continued use of Herceptin in this patient is within the community standard of care and is clinically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for gene panel testing provided. Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend molecular gene testing in appropriate cases. In this case, the patient has a complicated presentation as she has long standing ITP and her MDS can be caused by medication (Nplate) or possibly lupus if secondary MDS or could be primary MDS. Treatment would differ if primary versus secondary MDS. Primary MDS could be treated with a stem cell transplant and secondary MDS by withdrawal of medication or possibly treatment of underlying disease. In this clinical setting, molecular gene testing was likely to be more beneficial given that standard testing did not clarify if her MDS is primary or secondary. Accordingly, the gene panel testing provided was likely to be beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewers 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacroiliac joint fusion (CPT 27279). Findings:  The physician reviewer found that In addition, the authors found sacroiliac joint fusion to be more effective than nonsurgical treatment modalities. Polly and colleagues noted that, In this Level 1 multicenter prospective randomized controlled trial, minimally invasive sacroiliac joint fusion with triangular titanium implants provided larger improvements in pain, disability and quality of life compared to nonsurgical management. In this case, the patient has undergone maximal nonsurgical treatment with injections that have localized the pain to the sacroiliac joint. While there is adjacent level degenerative disc disease on imaging next to the prior lumbar fusion, it is remote from the pain site anatomically. Therefore, the requested sacroiliac joint fusion (CPT 27279) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 24-year-old male who was admitted to residential treatment in November 2005. The November 2005 admission note indicated an absence of any acute medical issues and the presence of normal vital signs. The patients last use of opiates was one week prior to admission. The note indicated the patient had a seizure (of unknown etiology) late in October 2005. A clinical assessment form dated in November 2005 indicated the patient was transferred from another facility where he had been admitted in October 2005 and was detoxified from methadone for the prior three days secondary to prescription pain medication dependence. This same form indicated the patient was without any suicidal or homicidal ideation and had a supportive wife with whom he was living. The patient did describe a history of depression, anger, anxiety and severe cravings. At issue is whether the residential treatment services provided from November 2005 through December 2005 were medically necessary for treatment of the patients medical condition.Review of the clinical evidence indicates the patient had already been detoxified medically at the time of his admission to residential treatment and there were no symptoms of significant withdrawal documented upon admission or during his stay. There is no evidence of medications being administered for withdrawal during the patients stay and there is no evidence of any medical monitoring during the placement. In addition, the records demonstrate the patient was motivated for treatment and although he had a history of depression, there were no suicidal or self-harm ideations noted. Furthermore, the patient had a prior history of sobriety and there is no documentation of treatment failure associated with his prescription medication dependence in the submitted records. Moreover, the patient had a supportive system available to him. For these reasons, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xifaxan. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients irritable bowel syndrome with diarrhea. The submitted documentation supports the medical necessity of the requested medication. This patient has irritable bowel syndrome, diarrhea-predominant (IBS-D). Xifaxan has been proven to be safe and effective in randomized placebo-controlled trials for IBS-D. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that Xifaxan is effective. Additionally, this patient has small intestinal bacterial overgrowth. Xifaxan has been shown to be highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief.  Per the medical evidence, this medication has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones, such as ciprofloxacin. The results are sustained for several weeks after treatment. The formulary alternative would not address small intestinal bacterial overgrowth. For these reasons, Xifaxan 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 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.