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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of the enrollee, who has been diagnosed with diabetes type 2.  Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Victoza (liraglutide) is used for weight loss management and to reduce blood sugar in patients with type 2 diabetes mellitus. The available medical studies indicate that Victoza is effective in the treatment of obesity-related risk factors and induces weight loss. From the forms provided, this patient was diagnosed with type 2 diabetes and had a body mass index of 40.88 at the time Victoza was sampled. In general, this medication has been known to lower hemoglobin A1C by about 1% point. Moreover, the Health Plan suggested that Victoza is medically necessary for treatment of type 2 diabetic patients who have an A1C of 7 or greater. This patient had an A1C of 6.5 in 2015. The provider indicated that the samples of Victoza and metformin were no longer effective in the treatment of this patient. As such, it is likely that if Victoza was discontinued, this patients A1C could rise to greater than 7. Therefore, the requested medication Victoza is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested for gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that based on review of the records, medical necessity has not been established for the requested bariatric surgery procedure. As noted in the medical literature by Smith and colleagues, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. This patients records do not document any of these conditions.  Accordingly, the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ThyGenX Oncogene Panel and ThyraMIR microRNA tests. Findings:  Three physician reviewers found while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. The testing performed in this case may allow patients to avoid unnecessary surgeries. Therefore, the ThyGenX Oncogene Panel and ThyraMIR microRNA tests were likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

An enrollee has requested authorization and coverage for hip replacement surgery.The American College of Rheumatology recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy includes exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Researchers have concluded that six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing total joint replacement to relieve symptoms.In this case, the patient has a history of chronic right hip pain and dysfunction. He reports severe right hip pain that is interfering with his ambulatory tolerance. There is radiographic evidence of severe right hip osteoarthritis. His pain is not currently controlled. The submitted documentation includes detailed evidence of recent, reasonable and comprehensive non-operative treatment including activity modification, medications, use of a cane, weight loss and steroid injection without sustained improvement. The patient has lost weight and reduced his body mass index. He has reported difficulty with additional weight loss, and bariatric surgery is reportedly contraindicated due to a large ventral hernia. He has met other evidence based medical criteria for hip replacement surgery. Current evidence based medical literature supports proceeding with hip replacement surgery in the setting of the current body mass index, indicating that obesity itself should not be a deterrent to undergoing total joint replacement to relieve symptoms. Therefore, the requested hip replacement surgery is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's 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 authorization and coverage for Ibrance for treatment of the enrollee, who has a history of breast cancer. Findings:  The physician reviewer found that first line therapy for metastatic breast cancer is dependent upon the presence or absence of estrogen/progesterone receptors and/or HER2. Patients with metastatic breast cancer often respond to endocrine therapy, and newer treatment options appear to prolong progression and possibly survival. In this case, the patient has received letrozole and progressed while on it. Therefore, alternate therapeutic options should be considered. Palbociclib is a CDK4 inhibitor. In a study, it analyzed the role of palbociclib (Ibrance) and fulvestrant compared to fulvestrant and placebo. This study demonstrated that the combination resulted in an improvement in progression free survival. Based on current guidelines and the results of a well conducted study, the use of Ibrance in this patients case is 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 partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and medical 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: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested chiropractic services for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The office notes do not document what particular vertebrae were adjusted on each office visit.  Although there is notation that the patients range of motion was improving, there is a lack of documentation regarding how much the range of motion increased or decreased in the office notes.  The records do not document the necessity of chiropractic services during the dates of service in dispute.  All told, chiropractic services provided during the said timeframe were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that the patient is asymptomatic with respect to her breasts. The patient has a history of a prior augmentation mammoplasty. The patient underwent a routine screening mammogram consisting of a combination two-dimensional (2D) and three-dimensional (3D) tomosynthesis examination. Implant displacement views were also obtained. In addition, the patient had an automated whole breast sonogram exam.  The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. No abnormalities were noted with regards to the implants. The whole breast automated sonogram also did not detect any abnormalities. Her breasts were described as extremely dense. In this particular patient, the presence of implants is not, in itself, an indication for tomosynthesis. For patients with implants, it is important to obtain implant displacement views to better evaluate the native breast tissue, which was done in this case. The patient also has breasts that have been described as extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in diagnostic radiology 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: A patient has requested authorization and coverage for Euflexxa knee injections. The submitted documentation supports the medical necessity of the requested medication. One study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan therapy were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical evidence supports hyaluronic acid injections in the knee as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. There is no maximum amount of injections established by high quality scientific evidence. This patient presents with recurrent right knee pain and functional limitations. Clinical examination findings are consistent with the diagnosis of osteoarthritis of the right knee, including medial and lateral joint line tenderness. The records indicate that reasonable conservative treatment, including pain medications and activity modification, has failed to provide adequate symptom relief. The patient reports gastric intolerance to nonsteroidal anti-inflammatory drugs. Prior viscosupplementation has provided significant pain reduction and improved mobility for six months. The medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Euflexxa knee injections are medically necessary for 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 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 residential mental health and substance use treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patients alcohol use permeated multiple functional domains.  Further compromising the clinical picture was the presence of a comorbid depressive illness and medical issues.  The record reflects that the patient had not consolidated the treatment gains necessary to succeed independently.  The patients primary support system was crumbling.  Her primary coping mechanism for most of her adult life had been drinking.  Based on these factors, it was likely that the patient would have promptly relapsed and required re-admission in the absence of residential programming.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  Additionally, the treatment course seamlessly transitioned to a comprehensive community-based program rather than a hasty discharge with a break in care.  Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 57-year-old male enrollee has requested proton beam radiation x45 (CPT code 77522) for treatment of his prostate cancer. Findings:  Three physician reviewers found that the treatment options for low risk prostate cancer include active surveillance, prostatectomy, brachytherapy or external beam radiation with photons or protons. There are studies comparing photons and protons. In the study reported by Yu and colleagues, comparison between men treated with protons and photons showed similar toxicity. The American Society for Radiation Oncology published an evidence-based review of proton beam therapy and concluded that although proton therapy holds promise, there is insufficient evidence that it is superior or even comparable to photon radiotherapy. Based on current data, proton therapy provides no demonstrated benefit over standard treatment with IMRT. Thus, the requested proton beam radiation therapy is not likely to provide this patient with an improved health outcome when compared to standard alternative therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy and 11.5 hours per month of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. A study found that intensive behavioral treatment for children with autism is effective. The Health Plan has recommended a decrease of ABA hours due to minimal progress. Although the patient has not had significant progress, the factors that support the need for intensive ABA therapy at the requested frequency include the patients self-injurious behaviors, tantrums and level of severity for stereotypy repetitive behavior. In sum, there is sufficient documentation supporting 20 hours per week of direct ABA therapy and 11.5 hours per month of supervision for treatment of the patients medical condition.  Final Result: The reviewers 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: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in developmental-behavioral 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: An enrollee has requested authorization and coverage for OxyContin 10 mg four tablets orally in the morning and three tablets orally in the evening for treatment of the enrollees fibromyalgia and chronic pain syndrome. Findings:  The physician reviewer found that The stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative settings. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient wants 105 MME per day and was on recently before 180 MME per day, even though the patient reported to being able to get by with 52.5 MME per day. There is no medical evidence based rationale is given for this high of a MME per day by the provider nor long term consequences with the continual increase. Risk and benefit analysis must be performed to justify the requested level of 105 MME per day. It is unclear what the plan is for any unseen future pain insults the patient would experience while already on 105 MME per day. Additionally, it appears that tolerance has taken place since the start of the narcotics. The medical evidence indicates that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There are no improved or changed objective function noted with the requested dose escalation to 135 MME per day. There are no clear objective goals established by the provider with this high dose of opioid. Other non-pharmacological methods of managing the pain have not been done or even addressed. The records do not mention behavior therapy despite much research to support its use. Final Result: The reviewer determined that the requested medication dosage 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 anesthesia 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

The patient is a seven-year-old male with a reported history of Aspergers syndrome who has received an initial evaluation for sensory integration therapy in August 2005 and visits from September 2005 through October 2005. He is working primarily on a sensory deficit. The submitted records do not include documentation from a developmental pediatrician or pediatric psychiatrist confirming a diagnosis of Aspergers syndrome. The Health Plan has denied coverage for past and future sensory integration occupational therapy on the basis that it is not medically necessary.Although sensory integration therapy is the standard of care for autism spectrum disorder, review of the submitted clinical information reveals no documentation of the diagnosis of Aspergers syndrome from a physician. Sensory integration abnormalities, in and of themselves, are not a diagnosis but rather symptoms. The therapy at issue is not medically warranted in the absence of a confirmed medical diagnosis. Accordingly, I have determined that the therapy at issue is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.