Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female has has requested approval for Oncotype DX Colon Cancer Assay for evaluation of her colon cancer.   Findings:  Two physician reviewers found that the patient presented with blood in her stool prompting a colonoscopy, which showed a right sided colon tumor. She underwent surgery and the pathologic stage was T3N0M0. The patient had 25 lymph nodes sampled and they were all negative for tumor involvement. There are no other reported findings suggestive of metastatic disease and the patients pre-operative CEA level was not elevated at 2.2. Following surgery, the patient had a discussion with her oncologist about adjuvant chemotherapy. The provider explained that some patients at her stage benefit in terms of overall survival and the Oncotype DX test may be predictive and help decide upon adjuvant chemotherapy use.  The difference between stage II and stage III colon cancer is the involvement of lymph nodes by tumor. The prognosis of stage III is worse due to the higher risk of relapse. The use of adjuvant chemotherapy in patients with stage III cancer improves overall survival and is the standard of care. In contrast, the rate of relapsed disease in patients with stage II colon cancer is reduced and so are the benefits of adjuvant chemotherapy. An effort has been made to identify those stage II patients that may benefit from adjuvant therapy with the Oncotype DX test, which is a quantitative assay for mRNAs of genes that may predict recurrence. A similar test has been effective in predicting recurrence risk in certain patients with breast cancer. For colon cancer, a large retrospective validation trial was performed and the strongest predictors of recurrence were tumor stage (pathologic T stage) and mismatch repair (MMR) status (Gray, et al). Based on this study, this patients T3 stage and extensive lymph node sampling predict a low risk of recurrence. Currently, there in a paucity of data to routinely recommend the Oncotype DX test for stage II patients. The American Society of Clinical Oncology reviewed the data in 2004 and issued a published analysis that does not support adjuvant chemotherapy as the standard in stage II patients (Benson, et al). Therefore, the requested testing is not likely to yield additional helpful information relevant to treating this patients medical condition than standard approaches.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for human growth hormone (GH) (Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL)) pen injector for treatment of the enrollees short stature.Findings:  The physician reviewer found that This patients height is more than two standard deviations (SDs) delayed, his growth velocity is poor, and his adult predicted height is just below 63 inches, which is shorter than expected for the genetic potential and  more than two SDs below the mean for his gender. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria, and his adult predicted height of less than 63 inches is short enough to warrant a trial of GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. All told, the requested human GH (Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL)) pen injector is supported as medically necessary for treatment of this patients short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 a referral to an orthopedic specialist. Current evidence-based, peer-reviewed medical literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for the initial evaluation and treatment. This patient presents with complaints of right fourth finger pain and swelling. He reported that he sprained his finger and he experiences pain while performing activities of daily living. There is radiographic evidence of periarticular soft tissue swelling at the fourth proximal interphalangeal joint with no evidence of acute fracture or dislocation. There is a lack of documentation that the patient has failed initial conservative management. Evaluation and management of these complaints is within the expertise of his primary care provider. Therefore, the request for referral to an orthopedic specialist is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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 60-year-old male enrollee has requested an increased dosage of Symlin (120mcg three times per day) for treatment of Type I Diabetes.  Findings:  The physician reviewer found that the approved dosage of Symlin for type I diabetes mellitus is 60mcg before meals at maximum. There is no data to support higher doses as useful.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. As noted in the medical literature, the DecisionDx-Melanoma test is a 31 gene assay of an individual patients melanoma cells that classifies melanoma into either Class 1 or Class 2, with a differing prognosis at five years. The National Comprehensive Cancer Network (NCCN) does not recommend routine use of the DecisionDx-Melanoma genetic testing for evaluation of patients with malignant melanoma, as in this patients clinical setting. Specifically, there is a paucity of data demonstrating that the use of the DecisionDx-Melanoma assay to direct treatment planning improves patient health outcomes when compared to standard risk profiling. Currently, DecisionDx-Melanoma testing is not recommended to help direct clinical decisions, such as the need for sentinel node biopsy and/or adjuvant therapy. Given these findings, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings: Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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 a Synvisc-One injection in the right knee only. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether a Synvisc-One injection in the right knee only is medically necessary for the treatment of the patients medical condition. 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. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation. Furthermore, her options are limited. The patient has tried and failed conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, a Synvisc-One injection in the right knee only 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for esophageal pH monitoring.Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. Combined 24-hour pH-impedance (pH-MII) and manometry can be used to diagnose rumination syndrome in children and to distinguish it from GERD. In this case, the patient had regurgitation several times per day consistent with rumination syndrome, in which postprandial regurgitation is common. pH monitoring reveals a distinct pattern in rumination syndrome versus refractory GERD, and provides objective data for diagnosis. The distinction is important because antisecretory therapy can make rumination symptoms worse, and rumination can be associated with nausea. For these reasons, the pH monitoring at issue is supported as medically necessary for the diagnosis of this patients regurgitation symptoms. Therefore, the esophageal pH monitoring at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for 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: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 4. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent 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 limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive; genotype 4 patients should be treated with Mavyret three tables daily for eight weeks. The ENDURANCE-4 trial showed a 99% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested a podiatry consultation for treatment of her onychomycosis and medical condition status post hip surgery.   Findings:  The physician reviewer found that based on the available medical records, even though the patient is six years post replacement, the implant continues to place the patient at risk for multiple medical problems including infection (Lora-Tamayo, et al). According to the American Academy of Orthopaedic Surgeons (AAOS), the loss of the replaced hip or secondary infection would require additional treatment. In this patients case, treatment by a podiatrist would help prevent infection or soft tissue necrosis, which may cause further health problems. Thus, the requested podiatry consultation to assess the patients disability impairing walking following hip surgery and to evaluate and treat the patients severe onychomycosis impairing the patients ability to walk is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the septorhinoplasty procedure for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service.  The proposed procedure involves a rhinoplasty with major septal repair.  Correction of a dorsal hump and bulbous tip would be more in line with cosmetic procedures and does not appear to be the result of the previous procedure.  Additionally, the requested services are not reconstructive in nature.  Per the medical records, there is some loss of support of the nose that could be considered an abnormal occurrence as a result of the previous medically necessary procedure.  However, there is not sufficient documentation that the dorsal hump and bulbous tip is significantly abnormal.  There is no evidence that the proposed procedure would improve function.  Based on the submitted documentation, there is insufficient justification that the rhinoplasty part would correct a significantly abnormal appearance.  All told, the requested services are not reconstructive in nature and are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 plastic 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 Prezcobix for treatment of his human immunodeficiency virus (HIV). Findings:  The physician reviewer found that Prezcobix is a combination tablet that contains both (darunavir) Prezista and (cobicistat) Tybost. Numerous studies have shown that simplified regimens for HIV can increase adherence and thus long-term successful suppression of HIV replication and more successful treatment of disease leading to decreased morbidity and increased survival. Thus, the Health Plans denial of this beneficial simplification is detrimental to the patients health and survival.  The standard of care dictates that the simplified regimen is better as it can increase adherence and long-term successful suppression of HIV. For the reasons, provided, the patients request for the simplified regimen of Prezcobix is medically necessary in this clinical setting.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 infectious 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: An enrollee has requested authorization and coverage for Northera. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Northera is approved for the treatment of neurogenic orthostatic hypotension. The drug improves symptoms of orthostatic dizziness, lightheadedness and near-fainting. Beta hydroxylase deficiency is characterized by both elevated dopamine and low catecholamine. Although the records mentioned the diagnosis of orthostasis, the recorded blood pressures available for review did not demonstrate orthostasis. Autonomic function testing, which is the definitive test, did not show orthostasis. In sum, this patient does not have documented orthostatic hypotension or evidence of cardiovascular autonomic dysfunction. Therefore, Northera 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: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested for occipital nerve stimulation implantation for treatment of her occipital neuralgia.   Findings:  Two physician reviewers found that the use of peripheral nerve stimulation for management of intractable pain has been discussed since 1977. In 1999, Weiner and Reed first described a technique for occipital nerve stimulation.  Since then, several articles published in peer-reviewed journals have suggested the efficacy of occipital nerve stimulation in the management of neuralgic pain (see Slavin, et al. and Kapural, et al.). These studies show evidence that clearly suggests the usefulness of occipital nerve stimulation in this condition. This patient has failed conservative treatment including multiple medications and epidural injections.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a motorized scooter for treatment of the enrollees medical condition. Findings:  The physician reviewer found that powered mobility can beneficial for well-selected individuals. The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem.  Determining of who will benefit is a matter of clinical judgment more than adherence to criteria defined by the peer-reviewed literature. This patient has been recommended for a motorized scooter due to poor balance, unsteady gait, poor endurance and a history of falls. In this case, the patients medical conditions and mobility deficits are amenable to a motorized scooter. All told, the request for a motorized scooter is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty 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.