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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Synvisc-One injection to the right knee. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this patients case, there is a history of immediate relief after the last injection that lasted six months. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Synvisc-One injection to the right 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: Upheld

A sixty-six year-old female diagnosed with recurrent disc dislocation, polymyalgia, myositis, cephalgia and capsulitis is requesting reimbursement for a neuromuscular scan, unlisted diagnostic radiologic procedure and electromyography.  Reviewers Findings:The reviewing physician found that the procedures at issue were either not medically necessary or not likely to be more beneficial than any standard treatment for evaluation of the patients medical condition.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of excellent results from Monovisc injections one year ago. The medical literature supports the requested repeated Monovisc injections of both knees as reasonable, appropriate, and medically necessary for treatment of this patients primary osteoarthritis of both knees, right worse than left. Given this support, the requested Monovisc injections in both knees 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 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 patient is a 44-year-old woman with a body mass index (BMI) of 48. She has undergone the necessary presurgical evaluations in preparation for weight loss surgery. The patient has requested authorization for the duodenal switch procedure. The Health Plan has denied the patients request indicating that the duodenal switch procedure is not medically necessary for treatment of the patients medical condition.Techniques in duodenal switch have been available since the 1980s. There is now sufficient data to show that duodenal switch has a superior long-term outcome when compared to gastric bypass for patients such as this patient. In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. Long-term studies of the duodenal switch procedure demonstrate equal effectiveness with less need for a highly restrictive diet than with gastric bypass. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old male enrollee has requested all-male group therapy for treatment of the enrollees eating disorder.  Findings:  Three physician reviewers found that the patient is receiving ongoing treatment incorporating standard therapeutic interventions. A psychiatric assessment notes the patient has made significant progress with the eating disorder. Additionally individual therapy note from this therapist reports the patient was following his meal plan, was cooperative and motivated, and denied any purging. Given the patients positive response to therapeutic interventions currently in place, there is no evidence to indicate than an all male group for treatment of his eating disorder is likely to be more effective than standard available therapy. Articles in peer reviewed medical literature, including the text from Herpertz-Dahlman and Hebebrand, and the American Psychiatric Association (APA), have not identified an all male eating disorder group as more efficacious than other available therapeutic modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for romiplostim. For chemotherapy-induced thrombocytopenia, thrombopoietin can provide benefit in the primary or secondary prophylaxis of thrombocytopenia. Clinical trials have shown improvement in patient platelet counts allowing for continued chemotherapy with use of romiplostim for this indication. In a case series of 20 patients treated with romiplostim for prolonged chemotherapy-induced thrombocytopenia, 19 patients demonstrated improvement in platelet counts, and 15 patients were able to resume chemotherapy at full doses. This patient has baseline thrombocytopenia. Without the use of romiplostim, the patient will not be able to continue chemotherapy. Therefore, romiplostim was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 medical oncology and hematology 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 patients parent has requested authorization and coverage for infusion J1745 Remicade 10 mg/kg (600 mg) every six weeks. Bauman and colleagues note that many pediatric patients with inflammatory bowel disease (IBD) lose response to infliximab (Remicade) within the first year, and achieving a minimal target infliximab trough concentration is associated with higher remission rates and longer durability. Low infliximab troughs increase the likelihood of loss of response and of increased IBD activity. Children with moderate-to-severe ulcerative colitis are at risk of low trough levels due to increased intestinal losses. In this case, the records note that the patient was treated with a high dose infliximab of 10 mg/kg, rather than the standard dosing of 5 mg/kg. The records show that the patient appears to have had a good response to this induction treatment, documenting an infliximab trough of 10 g/g at seven weeks following the previous dose, indicating that the high dose of 10 mg/kg was not excessive. Calprotectin had also normalized. Although a letter from the patients gastroenterologist referred to breakthrough symptoms, these were not apparent in clinical notes. Given that the patient does not appear to have signs or symptoms of a loss of treatment response, the requested increased dosing frequency of infliximab is not medically indicated. Therefore, infusion J1745 Remicade 10 mg/kg (600 mg) every six weeks is not medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested breast implant replacement surgery for treatment of breast implant deflation.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. Based on the entirety of the documentation submitted for review, the patient had original augmentation mammoplasty for aesthetic concerns, and has suffered known complications. There was no evidence that the initial surgery was performed for reconstructive reasons.  The patient is noted to have some functional compromise related to her implants, as she has pain. Although implant removal could be considered medically necessary, the request for breast implant replacement surgery is not medically necessary.  With regard to the whether the proposed breast implant replacement surgery meets reconstructive surgery criteria, the patient presents with a capsular contracture and a ruptured implant which can be considered an abnormal condition. There is some indication that the possible implant rupture may have been due to the previous imaging. However, this is not conclusive as the implant is not obviously ruptured on evaluation of the photographs. In addition, the requested surgery is not being performed to improve function or create a normal appearance to the extent possible. Implant replacement would not likely resolve the patients functional concern, but could lead to a recurrence of the condition. In addition, there is no evidence that the initial augmentation was performed for reconstructive reasons. The planned procedures are performed to correct previous aesthetic intervention. This implies a baseline relatively normal appearance. Thus, the corrective procedures are planned for returning to an improved appearance relative to normalcy. In addition, the photographs submitted for review show a relatively normal appearance. Finally, the proposed surgery may improve the appearance of the patient, but would tend towards improvement on normalcy. Therefore, the requested breast implant replacement surgery does not meet reconstructive surgery criteria.Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the requested Tymlos.Fractures are the most dangerous aspect of osteoporosis, which can lead to acute and chronic pain. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide. Liu and colleagues state, Anabolic agents, [such as Tymlos], have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested medication Tymlos is medically necessary for treatment of the patients medical condition.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: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that this is not revisional surgery. The patient has multiple obesity-related comorbidities that will be ameliorated or eliminated by bariatric surgery. She has passed medical and surgical evaluations. The requested surgery is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prostate urethral lift. Findings:  Three physician reviewers found the prostate urethral lift is a novel, minimally invasive approach to treating benign prostatic hypertrophy that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that this treatment is safe and effective in relieving lower urinary tract symptoms without significantly compromising sexual function. However, prostatic urethral lift is an invasive procedure, and medical therapy should be exhausted prior to using an invasive procedure. Alpha blockers, 5-alpha reductase inhibitors and anticholinergic medications are standard of care in this clinical setting. Additionally, the efficacy of this treatment in the setting of failure of transurethral resection of the prostate has not been demonstrated. Thus, prostate urethral lift was not likely to have been superior over other available treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in urology 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the genetic testing services provided by Esoterix Genetic Laboratories. Findings:  Two physician reviewers found that while hypercoagulable states can be found in patients who have had an ischemic stroke, widespread testing for these disorders is limited by a number of considerations. These factors include a relatively low prevalence of thrombophilias, and alteration of the sensitivity and specificity of the tests involved in the setting of an acute ischemic event. As discussed in the medical literature, it remains unclear whether inherited thrombophilias predispose patients to stroke as with deep venous thrombosis. Given the absence of data in the peer-reviewed medical literature demonstrating improved health outcomes with this testing, the genetic testing services provided by Esoterix Genetic Laboratories were not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.One reviewer found that genetic testing services provided by Esoterix Genetic Laboratories were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of 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:  One reviewer is board certified in internal medicine with subspecialty certification in hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for testosterone implants (Testopel). The treatment goal in androgen replacement is a return of testosterone levels to the normal range with a planned benefit of relief of associated symptomatology. However, there is a paucity of medical literature or clinical reports demonstrating superior health outcomes when the route of hormone administration is changed when normal range has been achieved without adverse effects. In this patients case, there is a lack of documentation to support treatment with testosterone implants in lieu of standard therapies. Given these findings, the testosterone implants (Testopel) were 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 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: Physician reviewers 1, 2, and 3 are board certified in urology 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: Upheld

A 40-year-old male enrollee has requested for a brain positron emission tomography (PET) scan for evaluation of her head pressure and cognitive deterioration.   Findings:  Three physician reviewers found that the use of PET scans for brain imaging is in its infancy. There are only a few accepted uses for PET scans of the brain including pre-surgical evaluation in patients with seizure disorders and to differentiate between fronto-temporal dementia (FTD) and Alzheimers disease. . Review of the peer-reviewed literature did not support the use of PET scan in the evaluation of neurodegenerative disorders. In conclusion, the requested PET scan is not likely to be more useful in evaluation of the patients medical condition than standard diagnostic modalities.