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

A 52-year-old female enrollee has requested Crestor for the treatment of her hyperlipidemia. Findings:  The physician reviewer found that patients with hyperlipidemia have several options available for therapy. Statin therapy has had the largest preponderance of positive data associated with decreased mortality and event reduction risk. There are many different drugs within the statin class, all of which are FDA approved for the treatment of lipid disorders, and intolerance is not a class effect. Therefore, intolerance to one or two statin drugs does not indicate intolerance to all statin therapies. The Health Plan formulary has choices of different FDA approved statins that may be as least as effective as Crestor without intolerant effects, and a trial of one of the formulary statins to assess for tolerance and efficacy would be a reasonable and a medically accepted clinical strategy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  Harvoni has been approved for the treatment of patients with chronic hepatitis C, genotype 1 infection.  The current medical evidence supports Harvoni for eight weeks for this treatment-naive patient with a viral load less than 6,000,000 IU/mL.  Based on the current medical literature, Harvoni for eight weeks is medically indicated 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling for evaluation of the enrollees melanoma. Three physician reviewers found the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add more to these statistics.  By Balch staging, this melanoma would be classified as a T1a, or stage 1A, with at least an 88% chance of ten-year survival. Decision DX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a greater than 90% chance of five-year, disease-free survival), or Class 2 (with a 48 to 77% chance of five-year, disease-free survival). It is not clear how the five-year Decision DX data compares to the ten-year Balch data, and, most importantly, whether it can be used to make clinical decisions.  Based on the current medical evidence, the superior efficacy of gene expression profiling has not been established. Final Result: The 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: 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

A male enrollee requested Jublia for medical treatment of his onychomycosis.  Findings:  The physician reviewer found that this patients medical condition, onychomycosis, would be most safely treated with a topical anti-fungal medication, because the patients liver problem precludes from using systemic anti-fungal therapies. The relative efficacy and safety profiles of Jublia, compared to other topical antifungal drugs, support its use in this case as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a Synvisc-One injection to the left knee. The patient has been diagnosed with osteoarthritis of the left knee. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent lasting pain relief from prior viscosupplementation injections. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection to the left knee is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Overturned

The parent of a two-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder. Findings:  The physician reviewer found that there is ample scientific data demonstrating that speech therapy and occupational therapy are safe and effective modalities for patients with autism. Given the documented deficits associated with this patients diagnosis of autism, it is medically necessary that he receive the requested speech therapy and occupational therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure (CPT 43284). Findings:  The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the FDA, more data are required before widespread usage can be recommended. Skubleny and colleagues concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, Sheu and Rattner reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Alicuben and colleagues found that erosion of the LINX device is an important but rare complication to recognize. Avazi and colleagues noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, the LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients condition than any available standard.Findings:  Two of the three physician reviewers found the requested LINX procedure (CPT 43284) 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 service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 60-year-old female who has an approximate one-year history of dry eyes and chronic eye irritation. Her physician has indicated the patient has attempted a number of treatments including artificial tears, lubricant ointments and Alamast, which were ineffective. Her physician also indicates she has had an excellent response to Restasis. The patient stopped taking Restasis in July 2004 and her physician states her condition has worsened since stopping Restasis. She is requesting further treatment with Restasis.The clinical evidence demonstrates prior to Restasis the patient had been treated for approximately one year with little benefit. Restasis is a newer but increasingly accepted therapy and, based upon the patients medical records, appears to be benefiting her condition. Although the Health Plan has concerns regarding the results of the patients Schirmer test, this is a rather variable and not overly accurate test - positive rose bengal findings are more helpful for patients such as this patient. The reality is no single test is better than the clinical impression. Furthermore, Restasis has been beneficial for this patient and is known to be effective in treating this patients condition. The patient has already failed other available treatments. Therefore, there is no need to re-institute these treatments. Because the patient is benefiting from Restasis and has failed appropriate alternative therapy, I have determined that the requested medication is medically necessary for the treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient psychiatric services treatment for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that formal thought disorders comprise the most serious of psychiatric conditions and this patient has a particularly debilitating illness burden. This patient has a court-ordered conservator. He has recurrent suicidal behavior, depression and disorganized thinking. His most recent medication regimen consists of antidepressant therapy and 23 antipsychotic tablets every day, including clozapine which is a medication typically reserved for the most severe cases. He survived a high-lethality suicide attempt. He has prior history of suicidality and psychiatric hospitalization. He has multiple risk factors and warning signs for suicide and has reportedly asked his family to buy a gun so he can kill himself upon discharge. Finally, the psychiatric consultant has determined that admission to an acute inpatient unit and treatment with electroconvulsive therapy is indicated. All of these factors support psychiatric placement at the acute level of care. The risk for suicide spikes the first week after discharge. In addition, the patient has been engaged in active care during the hospital course yet remains symptomatic. The acute inpatient setting would be reasonably expected to improve the patients condition, while preventing a more serious episode of illness, and represents a safe and appropriate disposition consistent with good medical practice. Additionally, ECT would be a logical treatment intervention in this particular case and is medically necessary. Final Result: The reviewers determined that the services at issue were and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that this patient has heterogeneously dense tissue on mammography which is known to limit the usefulness of standard mammography. The pathologic diagnosis of cellular atypia is a finding most pathologists consider to be a pre-malignant lesion. A detailed screening exam to evaluate for more advanced disease such as ductal carcinoma in situ (DCIS) is clinically indicated. MRI is the most sensitive means to evaluate the remainder of each breast in light of the pre-malignant nature of the biopsy material. Therefore, the breast MRI has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan of the thorax and abdomen/pelvis. Findings:  The physician reviewer found that the submitted documentation as well as the National Comprehensive Cancer (NCCN) guidelines demonstrate the medical necessity for the services at issue. According to NCCN guidelines, the conduction of CT scans at the two year mark conform to guidelines for this lymphoma.  The presence of the enlarging nodes noted in the pelvis caused the provider to plan a closer surveillance with CT. There was some concern of recurrence and the plan was to follow her with CT of the abdomen and pelvis four months later.  The decision by the provider to utilize CT scan adhered to the NCCN guidelines and standard practice. For these reasons, CT scan of the thorax and abdomen/pelvis provided for the evaluation of this patients medical condition was medically necessary. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 61-year-old female enrollee has requested Hyzaar for the treatment of her hypertension. Findings:  The physician reviewer found that patients with hypertension have several options available for therapy within the standard of care in clinical medicine. The Health Plan formulary has choices of different FDA approved antihypertensive agents that may be as efficacious without intolerable effects. However, this particular patient has been on a specific antihypertensive agent (Hyzaar) for several years with an efficacious control of her hypertension. Since this patient has no reported side effects and has been able to achieve and maintain control of her hypertension with Hyzaar, it is medically appropriate for this patient to continue use of this medication.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha Sureclick 140 for treatment of high cholesterol.  Findings: The physician reviewer found that the patient has documented peripheral vascular disease, dyslipidemia with elevated LDL cholesterol and intolerance to two statin medications. The provided records do not document coronary disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol in spite of standard therapy with proven outcomes benefit.  Based on the records provided, this patient has no documentation of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia by usual criteria (Raal and Santos).  This patient has no documented coronary artery disease.  In addition, the documentation does not support trials and intolerance to other different statin medications at low doses including fluvastatin or pitavastatin, both of which have lower side effect profiles. There is also no documentation that this patient has tried and failed Zetia which has proven outcome evidence of benefit (Cannon, et al). This patient has not exhausted proven standard therapy for treatment of his medical condition. As such, the medical necessity criteria for the use of a PCSK-9 inhibitor has not been met. Therefore, the requested Repatha Sureclick 140 mg/mL pen injector is not medically necessary for the treatment of this patient.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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for occupational therapy and physical therapy. Based on the available records, the requested occupational therapy and physical therapy are not medically necessary for treatment of this patient. The patient has undergone extensive therapy and been educated in a home exercise program. Documentation supports that the patients therapy has focused on upper and lower extremities with ankle and shoulder exercises. The records do not demonstrate that the skills of a professional therapist are required to facilitate this patients rehabilitation. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and deliver a program to maintain the patients current condition or to prevent further deterioration. All told, the requested occupational therapy and physical therapy are not medically necessary for 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 physical medicine and rehabilitation with subspecialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic esophageal sphincter augmentation (LINX). Findings:  Three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. For these reasons, the requested magnetic esophageal sphincter augmentation (LINX) is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: The patients parent has requested authorization and coverage for neurofeedback treatment. Biofeedback is a technique that enables a patient to learn how to change physiological activity to improve health and performance. Neurofeedback is the type of biofeedback most often discussed in research. Current medical literature categorizes neurofeedback as a complementary and alternative medical treatment for autism spectrum disorder. Evidence from well-controlled trials do not support neurofeedback as an effective treatment for autism. According to a recent study, the available studies do not support the use of neurofeedback in the treatment of autism spectrum disorder. This patient is currently receiving ABA therapy, which remains the gold standard to manage the behavioral issues specifically associated with autism. Therefore, the requested neurofeedback treatment is 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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.