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

A 20-year-old male enrollee has requested tetrabenazine (Xenazine) for treatment of his Tourettes syndrome. Findings:  The physician reviewer found that Tourettes is a complex neurologic condition, characterized by hyperkinetic movements, including motor and vocal tics, often associated with attention problems such as ADD, obsessive compulsive behavior, and learning disabilities. Regarding treatment strategies, the National Tourette Syndrome Association (TSA) states that, current evidence indicates that the clinical manifestations of Tourettes syndrome can be quite variable. It is, therefore, important to evaluate each patient closely to determine which aspects are most disabling. The author noted that, for example, school performance may be impaired by frequent tics, obsessive thinking, attention deficit, personality disorder, or various combinations of those difficulties. Overall, most patients will experience one or two of the clinical aspects that will predominate and can serve as specific target symptoms for therapy. In addition, one article from Lopez Del Val and colleagues concluded that Xenazine appears to be an excellent pharmacological agent for use in a number of pathologies that are accompanied by hyperkinesias; it is well tolerated and has few complications or side effects deriving from its administration. This patient has been diagnosed with Tourettes syndrome and has already undergone treatment with a variety of prior therapies with inadequate relief of tics or with excessive side effects. Given that Xenazine has been effective and well tolerated in this case its use is medically necessary for this patients ongoing care and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi in combination with Daklinza for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that 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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks or Sovaldi, peg-interferon and ribavirin for 12 weeks. This is based on the ALLY-3 study for Sovaldi and Daklinza and the BOSON trial for Sovaldi, peg-interferon with ribavirin (Nelson, et al; Foster, et al). AASLD/IDSA was cognizant of the known side effects of these medications when creating these guidelines, and recommend monitoring patients for side effects during therapy with adjustments if needed. In this case, the patient does not have any of the medical contraindications to peg-interferon as defined in the AASLD/IDSA guidelines, or to ribavirin as defined in the U.S. Food and Drug Administration-approved prescribing information for ribavirin. For these reasons, the requested treatment with Sovaldi and Daklinza is not indicated for this patient. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/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 AmniSure laboratory testing for evaluation of her early labor.  Two physician reviewers found that the AmniSure testing was not likely to be more effective for this patient than any available standard therapies. The AmniSure test is used to aid in the detection of premature rupture of membranes (ROM) when the patient reports signs, symptoms or complaints suggestive of ROM. According to American Congress of Obstetricians and Gynecologists the diagnosis of ROM is typically confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid. There is a lack of meta-analysis or randomized controlled trials demonstrating AmniSure is more beneficial than standard diagnostic methods. Therefore, AmniSure testing was not likely to be more beneficial than routine diagnostic methods.   Final Result: Two reviewers determined that the testing at issue was 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 obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing.  Two reviewers are board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI). Findings:  The physician reviewer found that this patients mammographic density was described as heterogeneously dense, not extremely dense, on the mammogram report. There were no equivocal findings on the mammogram to warrant a follow-up MRI or ultrasound of the breasts, and the radiologists recommendation was a one-year follow-up mammogram, not MRI examination as stated by her oncologist. There are no genetic predispositions to breast cancer documented in the records, such as BRCA mutation. The history of prior breast cancer is not considered an indication for postoperative screening breast MRI. All told, bilateral breast MRI performed was not medically necessary for the evaluation of this patient. Final Review: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Overturned

A 51-year old female has requested Afinitor in combination with Aromasin for treatment of her metastatic breast cancer status post total mastectomy.   Findings:  Two physician reviewers found that due to heterogeneous tumor behavior and treatment responses, survival varies significantly in patients with stage IV breast cancer. The medical literature suggests that steroidal and non-steroidal aromatase inhibitors are important drugs that have benefitted stage IV patients in randomized clinical trials (Bonneterre, et al). However, despite treatment some patients still experience tumor progression (Mouridsen, et al). In the setting of tumor progression, the mTOR pathway has been thought to account for resistance to endocrine therapy. In the BOLERO-2 trial reported by Baselga and colleagues, patients with early and advanced hormone receptor (HR) positive disease were randomized to Aromasin and Afinitor, an mTOR kinase inhibitor, versus Aromasin alone. Progression free survival was the endpoint and the analysis showed that the combination treatment arm had a 10.6 months median survival compared with 4.1 months for Aromasin alone. This was highly statistically significant showing improved progression free survival in patients receiving both drugs. Thus, although the use of Afinitor in this case is off-label, the medical evidence supports its use in patients who have failed standard endocrine regimens, and is therefore likely to provide this patient with improved survival over conventional alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Prometheus IBD sgi diagnostic test for evaluation of his medical condition.  Findings:  Two physician reviewers found that per the American College of Gastroenterology (ACG) guidelines for ulcerative colitis, the specificities of tests such as the Prometheus IBD sgi diagnostic test may make these assays useful in patients in whom no other clinical or pathologic features allow a diagnosis of ulcerative colitis or Crohns colitis (Kornbluth, et al). The ACG guidelines further state that the distinction between IBD and other diseases have important consequences in terms of counseling, prognosis, and the choice of medical and surgical therapies. Prideaux and colleagues noted that in 10-15% of patients with IBD who cannot be diagnosed accurately may benefit from a panel evaluating serologic markers given the diagnostic uncertainty. Plevy and colleagues found that other markers in the panel have proven utility in discriminating IBD from non-IBD. Given this patients diagnostic uncertainty, the Prometheus IBD sgi panel was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic testing at issue was likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  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: Upheld

Nature of Statutory Criteria/Case Summary: The American Academy of Neurology 2012 headache guideline, reaffirmed in 2015, provides evidence and recommendations for management of episodic migraine headache prevention that categorizes drugs into five categories, including Level A (highest evidence), Level B (next highest level of evidence), Level C (lowest level of evidence), Level U (evidence against) and Other. Level A includes triptans, antieplipeptics and beta blockers. Level B includes antidepressants and additional triptans. Level C includes angiotensin-converting-enzyme (ACE) inhibitors and alpha agonists. This accepted guideline does not include calcitonin gene-related peptide receptors like Aimovig, which was just approved by the FDA in May 2018. A recent report by the Institute for Clinical and Economic Review (ICER) also concluded that there is inconclusive evidence for the use of Aimovig compared to other established oral agents for the prevention of migraine.Per the patients treating physician, she has tried and failed several drugs for treatment of her migraines. There is no documented evidence of trial and failure of anti-depressants or ACE inhibitors; while the patients concerns about side effects from these drugs are noted, they are considered part of the established treatment protocol for migraine headaches. Most importantly, while it is acknowledged that calcitonin gene-related peptide receptors like Aimovig show promise, their use has not yet been incorporated into national guidelines and is not supported by recent literature. For these reasons, the requested Aimovig injection is not medically necessary at this time.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 neurology 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

A 60-year-old female enrollee has requested radiofrequency rhizotomy (CPT codes 64622 and 64623) for treatment her lumbar pain.  Findings:  Three physician reviewers found that the patients history is significant for pain in the lumbar area of the spine.  Imaging has revealed facet arthritis and scoliosis.  The patients prior treatment has included anti-inflammatory pain medications, prolotherapy, physical therapy, home exercises and chiropractic care.  She had intraarticular facet injections and medial branch injections for facet joint pain.   In this patients case, radiofrequency rhizotomy is likely to be the most efficacious treatment alternative. She has had various standard therapies without sufficient benefit. There is sufficient medical evidence demonstrating that the requested services are an efficacious treatment for low back pain that appears to be originating from the facet joints. As noted by Dreyfuss and colleagues and Leclaire and colleagues, facet rhizotomy often does provide long-term pain relief.  All told, there is sufficient evidence supporting the superior efficacy of the requested services in this clinical scenario.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old male enrollee (through his parental representative) has requested Vyvanse for the treatment of his attention deficit hyperactivity disorder. Findings:  The physician reviewer found that this patient has an established diagnosis of ADHD combined type in the moderate to severe range per the submitted psychiatric evaluation. He has been treated with Vyvanse with positive results. Vyvanse is FDA approved for the treatment of ADHD in adults. According to the patients mother, while the patient was treated with Vyvanse he did not crave use of methamphetamine. The relevant medical literature includes an article by Najib which states that Vyvanse is efficacious for ADHD and may be an integral part of a total treatment program for ADHD that can include other measures such as psychological, educational, and social interventions. The author also indicates that Vyvanse is believed to have fewer side effects and less potential for abuse than alternative treatments. Vyvanse is medically indicated for the patients diagnosis of ADHD and has already been tried by this patient with good results.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing for evaluation of her pregnancy. Findings:  The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting.  This patient presented at 38 weeks with discomfort.  She reported passing her mucus plug, which would be a normal event at this stage of pregnancy. She denied ruptured membranes. She was seen and examined, and despite the negative history and examination, including negative ferning of the vaginal swab and normal amniotic fluid on ultrasound, AmniSure test was done to determine whether there was any amniotic fluid leaking.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure testing.  The records do not document that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that nitrazine testing was performed. The routine use of AmniSure to diagnose ruptured membranes is not recommended.  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 1, 2, and 3 are board certified in obstetrics and gynecology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL syringes. Kaye and colleagues report on the case of a patient with bullous pemphigoid who was successfully treated with dupilumab, an interleukin (IL)-4 alpha antagonist. Abdat and colleagues report in a case series of 13 patients that dupilumab may be an additional treatment for bullous pemphigoid, leading to disease clearance or satisfactory response in 92.3% of patients, including in those in whom previous conventional therapy had failed. Dupixent is not immunosuppressive and is well tolerated by most patients. Given the severity of the patients disease and this patients immunosuppressed status, the requested medication is medically indicated. Therefore, Dupixent 300 mg/2 mL syringes are 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 dermatology 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 57-year-old woman who has a long history of low back pain. The patient has participated in several treatment modalities including physical therapy, steroid injections, and medications; the patient continues to experience pain. She wishes to undergo lumbar spine surgery. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. Upon review of the submitted clinical information, there is no medical necessity for lumbar spine surgery. There is lack of agreement between the results of the MRI and the discography. Thus, the levels causing the patients pain cannot be precisely defined. As such, the patient is not likely to benefit from lumbar spine surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman who experiences chronic muscle tension headaches. She has undergone multiple diagnostic procedures. The results of these procedures have been normal, thus confirming the diagnosis of muscle tension headaches (the most common form of chronic headaches). She has been followed by a pain management specialist who has treated her with a large number of medications, which the patient reports have not provided relief. The patient has requested authorization for a referral to an out-of-network headache specialist. The Health Plan indicates the requested referral is not medically necessary.The patient does not require the care of a headache specialist. Although the patient continues to experience tension headaches, there is no evidence that ongoing care from a headache specialist will result in an improved clinical outcome. The patient can be appropriately treated by a pain management specialist with strict compliance to a long-term program. Therefore, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 23-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he or she was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient presented with visible exudate, or pus, on the pharynx. On physical examination, the provider recorded pain, fever, and difficulty swallowing. All of these symptoms are characteristic of a bacterial infection that a prudent layperson would consider to require immediate medical attention. The patient was prescribed an antibiotic and was able to begin treatment immediately for his condition in lieu of waiting for the end of the weekend to be seen by his primary care provider by which time his condition could become even more acute.
Appeal type: Urgent Care
Decision: Overturned

A 54-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient was suffering from a viral infection which caused coughing, headache and tactile fevers. This was an acute illness. He had seen two physicians in the previous five days and had been prescribed medication that did not improve his condition. Although it does not seem to have caused him severe pain, he was suffering from a persistent cough so severe that a prudent layperson would make a reasoned decision to seek immediate emergency care. In this case, it was important to rule out other diseases such as pneumonia, tuberculosis, as well as cardiac diseases that may cause patients to present with similar symptoms.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested for inpatient hospital services for treatment of her post right L4-L5 laminotomy, foraminotomy and microdiscectomy of extruded sequestered fragments. Findings:  The physician reviewer found that in a study to ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population, one page questionnaires were submitted to each neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. With respect to discharge from the hospital, 58 percent were discharged on the day after surgery, 18 percent were discharged on the same day and 23 percent were discharged in two days. Based on these data, it is apparent that discharge from the hospital on or before the second postoperative day is a common practice following lumbar discectomy, and discharge from the hospital on the third day is rather uncommon. Extenuating circumstances that would potentially justify postoperative hospital stays of three days or longer include continued nausea or vomiting, urinary retention, hemodynamic instability, fever, infection, pain not relieved by oral pain medications, inability to ambulate or a condition requiring possible additional procedures, such as a cerebrospinal fluid leak or hematoma formation.