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

A 44-year-old male enrollee has requested surgery involving the lip for treatment of his medical condition. Findings:  The physician reviewer found that in this patients case, the requested services are not medically necessary.  The medical records do not support the requested services in this clinical setting.  Photographs  show normal symmetric lip movement on smiling and lip pursing. There is no visible deformity or functional abnormality of the right or left upper lip.  The alleged abnormality does not constitute an abnormal structure of the body as there is no visible deformity in the included photographs.  The requested services will not improve function as it is currently normal.  It will also not create a normal appearance as the appearance is currently normal.  The proposed surgery would not provide any improvement in the appearance of the patient.  All told, the requested surgery involving the lip is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested acupuncture for treatment of the enrollees lateral epicondylitis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The medical records document lateral epicondylitis.  There is sufficient support for acupuncture in this clinical setting.  Trinh and colleagues performed a systematic review of the efficacy of acupuncture for the treatment of lateral epicondylitis.  The authors noted that the reviewed studies suggest that acupuncture was effective for the short-term relief of lateral epicondyle pain.  Trudel and colleagues conducted a systematic review to evaluate the efficacy of conservative treatments for lateral epicondylitis.  The authors noted that several treatments, including acupuncture, show positive effect in pain reduction or improvement in function.  All told, acupuncture is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of his neurological condition. Findings:  Three physician reviewers found that this patient does not meet the clinical criteria for either multi-focal motor neuropathy with block or chronic inflammatory demyelinating polyneuropathy required for diagnosis. Clinically and by electrodiagnostic testing, it appears the patient has ALS, lower motor neuron variant. There is no evidence that IVIG under these circumstances would be helpful or result in an improved clinical outcome. The patients condition is consistent with ALS based on EMG and laboratory results.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested hyperthermic intraperitoneal chemotherapy (HIPEC) laparotomy for treatment of her ovarian cancer.  Findings:  Three physician reviewers found that The National Comprehensive Cancer Network (NCCN) guidelines do not include HIPEC in their recommendations for post-surgical management of resected ovarian cancer. Conventional (non-hyperthermic) intraperitoneal therapy is recognized as an option. One review concluded that HIPEC as consolidation therapy requires further investigation (Helm). There is a paucity of high quality prospective trials showing benefit over standard of care. Based on the lack of peer-reviewed medical literature demonstrating the safety and efficacy of the requested HIPEC treatment, the requested therapy is not likely to be beneficial when compared to conventional care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. Despite some controversy about the effectiveness of screening (Nelson, et al), there is some evidence that early intervention can improve speech and language skills over short term follow-up. This service is typically provided when children demonstrate a 25% delay in a particular developmental area, such as this patient demonstrates. A 2004 systematic review determined that speech and language therapy might be effective for children with phonological or expressive vocabulary difficulties (Law, et al. 2004). A more recent systematic review by the Cochrane Collaboration reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties (Law, et al. 2010).  The standard of care for patients with the speech and language delay to the degree that this patient demonstrated in April 2010 would be speech and language therapy and reassessment. Since no evidence has been provided demonstrating that the patients condition has improved since this evaluation, the requested therapy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus.   Findings:  Two physician reviewers found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for eight weeks in this case. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest wall oscillation (HFCWO) system. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees recurrent pneumonia.Findings: There is support in the medical literature for the medical necessity of the requested device in this clinical setting.  High frequency chest wall oscillation (HFCWO) was developed to improve airway clearance in those where normal mucociliary transport system has failed (chronic bronchitis, bronchiectasis, and cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. However, the research bears out the utility of these systems in airway clearance. There is sufficient peer reviewed literature to support the efficacy of this device in this patients case. This patient has a history of very complex pulmonary disease with chronic lung disease and pulmonary hypoplasia, as well as gastrointestinal disease resulting in recurrent aspiration pneumonia despite fundoplication. The enrollee has had recurrent pneumonia and chronic cough demonstrating his inability to adequately clear his airway. With the severity of his gastrointestinal disease, standard airway clearance techniques are not appropriate and this patient would be at significant risk of developing bronchiectasis if he does not maintain adequate airway clearance. This has been borne out with demonstrated improvement upon initiation of HFCWO for airway clearance. As such, continued use of HFCWO for airway clearance (vest therapy) is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested device 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  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 acute hospitalization level of care, subacute hospitalization level of care, a chest computed tomography (CT) with contrast, and abdominal CT with contrast. The records provided for review document that this patient has undergone an extensive work-up and evaluation with multiple specialists for her ongoing symptoms of intermittent, small-volume emesis, and atypical chest pain. The patient has been hemodynamically stable with intermittent vomiting. The patient does not have any medical conditions that require acute or subacute hospital level of care services. Accordingly, the requested acute hospitalization level of care, or subacute hospitalization level of care, is not medically necessary for treatment of this patient. The patient has chest pain that has been described as atypical in nature. Diagnostic tests have included x-rays, echocardiogram, and electrocardiogram with cardiac enzymes. A CT with contrast of the chest was requested to rule out an aneurism or the aorta as the source of the patients recurrent chest pain. The clinical presentation of the patients chest pain is not consistent with an aortic syndrome that would include an aortic aneurysm, aortic dissection, or an aortic ulcer. According to the providers progress notes, the patient continues to be medically stable and is at her new baseline. The patient does not have any active medical issues that require diagnostic imaging. She is tolerating enteral feeding via her PEG tube and there is no indication of infection. There is no indication that her symptoms of emesis will resolve as she is being treated with Reglan for gastroparesis and has a PEG tube for nutrition. There is no indication that she is malnourished as her albumin is 3.4 and her weight has been stable for at least two months. The emesis is likely due to excessive saliva production and poor control over oropharyngeal secretions. The most recent laboratory studies are negative for significant electrolyte abnormalities. Given these findings, the requested abdominal CT with contrast is not medically necessary for this patient. All told, the requested acute hospitalization level of care, subacute hospitalization level of care, a chest CT with contrast, and abdominal CT with contrast, 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 internal medicine with expertise in skilled nursing facilities 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

A 40-year-old male enrollee has requested injections of Orthovisc for treatment of his left shoulder osteoarthritis. Findings:  Three physician reviewers found that the requested therapy is not likely to be more effective than other treatment modalities in this patients case.  Orthovisc is indicated for the treatment of pain due to osteoarthritis of the knee and temporomandibular joint in patients who have not responded to conservative treatment.  The superior efficacy of the requested therapy has not been established for the shoulder joint.  There is a lack of peer-reviewed data demonstrating the safety and efficacy of Orthovisc injections in this clinical setting.  Current clinical guidelines do not support the requested therapy for the treatment of shoulder osteoarthritis.  All told, three Orthovisc injections are not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee requested laparoscopic adjustable gastric band (lap band) surgery for medical treatment of his obesity. Findings:  The physician reviewer found that based upon the documentation provided, the patient appears to meet National Institutes of Health (NIH) criteria for bariatric surgery based on body mass index and the presence of obesity associated medical co-morbidities including obstructive sleep apnea and hypertension (Jensen, et al.) However, further work-up by a bariatric surgeon is needed to rule out any barriers to surgery, obtain psychiatric clearance, etc. While it was determined that a consultation with a bariatric surgeon to discuss the possibility of weight loss surgery is not indicated unless the patient has undergone a medically supervised weight loss attempt, there is a lack of peer-reviewed literature supporting this requirement. To date, it has not been scientifically validated that participation in pre-surgical medically supervised weight loss programs results in better clinical outcomes.   In accordance with the above, a bariatric surgical consultation is medically necessary for the patient. If following the consultation the bariatric surgeon determines lap band surgery is medically necessary, the patients request for surgery should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested BRCA genetic testing (BRCA 1 and BRCA 2) for evaluation of her breast cancer.  Findings:  Two physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance and could determine the adoption of special measures aimed at risk reduction. Well established guidelines identify patients in whom genetic screening is warranted. This patients relevant history consists of a personal history of breast cancer at age 50 and a first degree relative in her mother who was diagnosed with pancreatic cancer in her 70s. She further reveals that third and fourth degree relatives died from breast cancer. As per the criteria provided by the National Comprehensive Cancer Network (NCCN), a patient with breast cancer diagnosed at age 50, with one or more close relative diagnosed with breast cancer at any age, should be evaluated with BRCA screening. The records provided for review demonstrate that this patient satisfies these criteria, and as such the requested BRCA screening is warranted and likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that the fact that Lyrica is not officially approve for the indication of trigeminal neuralgia by the Food and Drug Administration, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology. In addition, there is clinical experience supporting the use of Lyrica for this condition as a very effective medication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (procedure codes 81415, 81416 and 81460). There is sufficient support for the requested services in this patients case. When determining the appropriateness of genetic testing, the first essential step is clinical evaluation. In instances where phenotypic presentation does not yield a diagnosis, exome sequencing may be appropriate. Currently, exome sequencing is generally indicated for undiagnosed neurologic disorders with nonspecific or clinically heterogeneous phenotype, following expert evaluation with detailed history and examination, and negative initial genetic testing when deemed appropriate. For this patient with gross motor delay, speech delay, dysmorphic features, and family history, exome sequencing is indicated based on the current literature. Therefore, genetic testing (procedure codes 81415, 81416 and 81460) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 pediatrics 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 Rituxan injection. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees myasthenia gravis.Findings: There is current literature to support the use of Rituxan (rituximab) in patients with refractory myasthenia gravis. Myasthenia gravis therapy has improved significantly and can be managed effectively. Many patients can achieve sustained remission and that is the goal. In general, rituximab has proven to be relatively safe in other autoimmune disorders as well as in myasthenia gravis. Myasthenia gravis is a common disorder of neuromuscular junction. The disorder is characterized by a fluctuating and variable combination of weakness in ocular, bulbar, limb, and respiratory muscles. Weakness is the result of an antibody attack directed at proteins in the neuromuscular junction. The diagnosis of myasthenia gravis can be established by clinical and serologic testing as it was in this patients case. The therapeutic approach is highly individualized for each patient depending upon the age of the patient, the severity of the disease, particularly dictated by respiratory or bulbar involvement, progression, and response to therapy. In this case, the patient has responded poorly to recognized standard therapy of prednisone, IVIG, and Mestinon. Rituximab is a monoclonal antibody against B cells. There is sound theoretical rationale as well as data supporting its use in patients with myasthenia gravis especially in individuals with MuSK antibody. Several studies show that rituximab is particularly effective for MuSK antibody subset of myasthenia gravis. In this patient, who has refractory myasthenia gravis and is on multiple standard therapies with poorly controlled myasthenia gravis, Rituxan has been demonstrated as medically necessary.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 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.