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 in the left knee. In the medical literature, researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 patients. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. In addition, the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. However, researchers noted that evidence from eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations and which populations are likely to benefit. This patient presents with persistent left medial knee pain and recurrent effusion. He is status post left knee arthroscopy, partial medial and lateral meniscectomy, chondroplasty, and debridement on 8/16/18. He has been diagnosed with moderate medial compartment osteoarthritis. Detailed evidence of a recent comprehensive non-operative treatment protocol trial, including two aspirations and corticosteroid injections, activity modification, ice, medications, and physical therapy, and failure has been submitted. Evidence-based medical peer-reviewed literature and guidelines supports the use of viscosupplementation injections as an option for the treatment of pain in patients with osteoarthritis of the knee in this clinical setting. Given this patients presentation, proceeding with the requested Synvisc One injection for the left knee is supported as medically necessary.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: Upheld

A 38-year-old female enrollee has requested for IVIG therapy for treatment of her immunodeficiency. Findings:  The physician reviewer found that laboratory evaluation shows a reduced level of IgG and a poor response to pneumococcal serotypes, but the variance from normal is not so great that IVIG therapy, in the absence of recurring bacterial infections, is warranted. The patients sinus CTs are not consistent with a prolonged history of significant infection. Additionally, there is no history of pneumonia, skin infections or chronic urinary tract infections. Regular monitoring of IgG levels and on-going work up on the patients symptoms appears appropriate at this stage.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male has requested gastric bypass revisional surgery for treatment of morbid obesity.  Findings:  The physician reviewer found that there is no indication the patient is manifesting blind loop syndrome due to an enlarged afferent limb. If he were indeed experiencing intermittent obstruction, the condition would lead to excessive weight loss and dehydration, not weight gain. Weight regain after a Roux-en-Y gastric bypass is typically due to dietary indiscretion. Revisional surgery would only be indicated in the following situations: breakdown of the staple line with gastrogastric fistula; anastomotic stricture; or previous vertical-banded gastroplasty with intractable reflux or stricture. The patient does not meet these criteria and the possibility of reflux suggested in the  upper GI report is not supported by the esophagogastroduodenoscopy findings.
Appeal type: Urgent Care
Decision: Overturned

A 43-year-old female enrollee has requested for urgent care services on an urgent basis. Findings:  The physician reviewer found that the patients physical examination was notable for wheezes, with no history of asthma. The patient was afebrile and was discharged with a diagnosis of upper respiratory infection. The patient was prescribed an albuterol inhaler and a narcotic cough suppressant. Her symptoms were severe enough for a prudent layperson to seek urgent care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of urgent care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance angiography (MRA). The medical records do not document a family history of aneurysm. In addition, there are no records indicating increased risk of vascular disorder and there is no indication of inflammatory response involving the vessels. MRA is supported when there are focal neurologic findings consistent with disruption of blood flow in distribution of a cerebral vessel or suspicion of inflammatory response or family history of cerebral aneurysm. Medical literature supports MRA of head when there are focal neurologic findings in the setting of trauma or suspected trauma or underlying collagen vascular disorder. Medical literature noted that MRA is of limited use in evaluation of headache without focal neurologic finding. Researchers reported MRA may be considered in patients with focal neurologic findings supporting vascular disruption but is not supported for migraine headache evaluation. All told, the MRA performed on 12/7/17 was not medically necessary for the evaluation of the patient based on the medical records provided for review. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy.In this case, the provider notes that proton therapy is necessary because the patients treatment field is close to her pacemaker and in order to improve sparing of her lungs and heart. The plan comparison was reviewed in detail. The heart mean dose was 7.6 Gy with IMRT and 5.7 Gy with protons. The pacemaker maximum dose was 13 Gy with IMRT and 0.5 Gy with protons. The decrease in dose to the pacemaker seen on comparative planning is not sufficient justification for the use of proton therapy. Treatment with proton therapy is associated with a higher incidence of neutron scatter compared to standard photon treatment, which could lead to greater interference with the device independent of the dose received. One study found a device malfunction rate of 20% with treatment to the chest with protons. Therefore, treatment with protons in this case would not decrease the chance of device malfunction despite the lower dose to the device. The standard approach would be to interrogate the device after every radiation treatment to ensure the device is working. The dose to the heart and lungs is also not sufficient justification for the use of proton therapy, as a phase 3 trial found no major clinical benefit to the use of proton therapy despite lower doses to these structures. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting. Accordingly, the requested proton beam radiation therapy is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 colorectal cancer for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the evidence regarding healthcare outcomes of Cologuard is lacking at this time.  Cologuard has been approved to test for colon cancer, and can detect most adenomas if they have high-grade dysplasia.  However, although Cologuard may be able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop.  The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined.  Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer.  Based on the current evidence, the services at issue were not likely to have been superior over other methods of evaluating this patient.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni. These 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 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni is medically necessary for the treatment of 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: Experimental/Investigational
Decision: Upheld

A 42-year-old female has requested a repeat right-sided uterine artery embolization for treatment of her uterine fibroids.   Findings:  Two physician reviewers found that the patient has a history of diabetes and is status post kidney-pancreas transplant.  Her provider noted that the she had episodes of complete urinary retention related to large fibroids during the past two years.  The provider noted that a non-hysterectomy approach was preferred in light of the patients transplant status.  The submitted documentation noted that the patient has to self-catheterize for complete bladder emptying.  Uterine fibroid embolization is based upon the hypothesis that reduction of myometrial arterial blood flow will result in infarction of fibroids and control of symptoms. It is an option for symptomatic premenopausal women who wish to retain their uterus, avoid side effects associated with prolonged medical therapy, and avoid surgical treatment.  However, there is insufficient evidence in the peer-reviewed medical literature to show the long-term efficacy and safety of a repeat uterine artery embolization for the treatment of uterine fibroids after initial artery embolization has failed.  Although uterine artery embolization is an effective primary treatment for leiomyomas, studies have recorded a recurrence rate of 10% at just more than two years.  Longer follow-up and more events are needed to define risk factors for recurrence.  Hysterectomy and myomectomy are considered the gold standard for the treatment of uterine fibroids and would not cause concern for compromising the transplanted kidney function.  All told, the requested repeat (right-sided) uterine artery embolization is not likely to be superior over other available treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement and prospective authorization and coverage for 10 hours per day partial hospitalization program level of care services. The submitted documentation supports the medical necessity of the services at issue. During the disputed timeframe, the patient continued to struggle with laxative use as well as anxiety and panic. The records documented non-compliance with her meal plan. She was noted to engage in excessive exercise. The patient also engaged in self-harm behavior and expressed passive suicidal ideation on several occasions. The patient has a composite score of 20 which correlates with partial hospitalization program level of care. Therefore, 10 hours per day partial hospitalization program level of care services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male with a history of expressive and receptive speech delays is requesting speech therapy.  Additional information in the form of an Individual Education Plan (IEP) has been submitted documenting the educational need for speech therapy.Reviewers Findings:  The reviewing physician found that the IEP documentation provides no further evidence that the speech delays are the product of a disease, injury, congenital anomaly or prior therapeutic intervention.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for radiofrequency nerve ablation. Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting. Failure of the second radiofrequency ablation to produce analgesia is not an uncommon problem. Son and colleagues reported up to 15% of repeat radiofrequency ablation procedures fail to produce adequate analgesia. Derby and colleagues found wide variation in the efficacy and diagnostic accuracy of medial branch blocks, with false negative response rates of 47.1%.  When the radiofrequency ablation fails, there may also be disease progression. It is not indicated to repeat a failed procedure. Therefore, the requested radiofrequency nerve ablation is not likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees arthritis.Findings:  The submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. Behavior therapy has been discussed but has not been completed despite much research to support its use. In addition, the records do not indicate that all non-opioid medication classes have been optimized or tried. Specifically, there is no mention of adding a tricyclic antidepressant, and/or gabapentin noted. In addition, there are other forms of treatment options available to this patient. Finally, since there is anxiety noted, the addition of Lyrica is not recommended. For all of these reasons, the requested authorization and coverage for Lyrica has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested authorization and coverage, and reimbursement, for the medical device, eNeura sTMS mini. The enrollee describes her migraine as a visual aura, followed by numbness and tingling of the face, arm, and leg, or blank spots in her vision. She is exhausted afterwards and requires several days to recover. Magnetic resonance imaging, magnetic resonance angiography, and an electroencephalogram were all unremarkable. Medical records report she has tried multiple medications; including Verapamil, Topamax, nortriptyline, Riboflavin, Magnesium, Motrin, Zonisamide, Maxalt, and Effexor. The enrollees provider reports she has been using the eNeura sTMS mini device for about a year and a half. The enrollee states that, since she has been using the device, she has achieved improvement in the amount and length of migraine episodes. Transcranial magnetic stimulation has been shown to reduce the frequency and severity of migraine headaches. Researchers report a randomized study of adults who experienced four or more migraine attacks per month showed a reduction in migraine and an improvement in visual analogue scale scores. A professional societys consensus statement reports transcranial magnetic stimulation is an option that may be effective for acute migraine, and for preventive treatment of migraine, especially in those for whom pharmacologic treatment is contraindicated, poorly tolerated, ineffective, or not preferred.  This enrollee has tried medications without success.Final Result: Two of the three reviewers determined that the requested service was likely to have been, and is likely to be, more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology 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

A 53-year-old female enrollee has requested for IV Rocephin infusions for treatment of her stated condition of Lyme disease.   Findings:  Three physician reviewers found that treatment of Lyme disease with long-term antibiotics is a controversial subject. Currently, there are two sets of guidelines (IDSA and IILADS). There is no objective evidence of persistent infection with Borrelia (Lyme) or other infectious agent in this particular patient. Numerous long courses of antibiotics have been used without success. Therefore, I would consider further treatment with intravenous Rocephin for greater than thirty days to be experimental or investigational in nature, since no large-scale, controlled trials have concluded that the proposed treatment is effective.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Stelara injection.  Findings:  The physician reviewer found that the patient has tried and failed therapy with topical steroids, methotrexate, and Enbrel.  Per the Health Plans guidelines, Stelara may be covered if the patient has tried and failed both Enbrel and Humira.  As these medications work by a similar mechanism of action, inhibition of tumor necrosis factor signaling, it is not expected that use of one would be successful when there is poor efficacy of the other.  The patient has failed topical therapies, ultraviolet light, an oral systemic agent and an anti-tumor necrosis factor biologic.  The patient has already had a treatment trial with Stelara injections, and it has been efficacious.  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 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.