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

A 70-year-old male enrollee has requested right eye canaloplasty surgery and prospective canaloplasty of the left eye for treatment of his glaucoma.  Findings:  Two physician reviewers found that a glaucoma specialist performed a canaloplasty on the patients right eye with results and has recommended the same procedure for his left eye. The provider in this case presents his rationale for the procedure in that canaloplasty is a safer, more effective alternative than traditional trabeculectomy. The current research confirms this concern as there is a significant complication rate with trabeculectomy, even in the best of circumstances. In addition, the American Academy of Ophthalmology (AAO) reported that canaloplasty is part of the current standard of care in glaucoma treatment and surgery. The services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue is whether platelet rich plasma (PRP) injections that were provided were likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. He has been diagnosed with bilateral knee osteoarthritis. The complaints included pain associated with locking and instability. Previous treatments included activity modification, medication therapy, and cortisone injections. The physical examinations demonstrated a decreased range of motion, tenderness, and effusion.Two out of three physician reviewers found that the effects of PRP on knee OA are mixed, and the research is not of high quality. The majority of published data suggests better symptomatic relief with early OA. The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for the treatment of osteoarthritis of the knee give an inconclusive recommendation for the use of PRP use in the treatment of knee arthritis.  An inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. In this case, the patient is being treated for bilateral knee osteoarthritis. Review of the available literature using PRP for the treatment of knee osteoarthritis fails to demonstrate that the requested treatment significantly changes outcomes or results in better or more durable pain relief than other standard therapies. Therefore, the PRP injections provided were not likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing.Findings:  Three physician reviewers found that the services in issue were not indicated under these circumstances. The determination of ROM during pregnancy is very important to determine next steps in management. In clinical practice, the diagnosis of rupture of membranes can sometimes be difficult and equivocal. The American College of Obstetricians and Gynecologists (ACOG) has noted that several commercially available tests for amniotic proteins are currently on the market, with high reported sensitivity for premature rupture of membranes (PROM), however, false-positive test result rates of 1930% have been reported in patients with clinically intact membranes and symptoms of labor. The standard of care usually includes a review of the patient's history and clinical exam, including a sterile speculum exam (SSE). If those findings are inconclusive, additional testing can be used. However, in this case, there is no documentation that a SSE was performed or reviewed before ordering the AmniSure test. Under these circumstances, the AmniSure testing that was performed was not more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services in issue were 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 obstetrics and gynecology 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

A 29-year-old female enrollee has requested for inpatient level of care services for treatment of her depression secondary to chronic pain.  Findings:  The physician reviewer found that applying the recommendations from the American Psychiatric Association (APA), this patients long history of treatment for medical and psychiatric issues combined with her uncontrolled behavior and recent suicide attempt, required inpatient treatment. The patients recent stressors increased her pain and decompensation of her mood and adjustment disorders. At the time of treatment, she was a serious risk to herself and others and to potentially decompensate further with more drug use.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as dense. It is specifically this type of patient with 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. Thus, in this clinical setting, the use of 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: All three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets for 12 weeks for treatment of hepatitis C.  Findings:  The physician reviewer has 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present (as in this patients case). These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present.  When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines. For these reasons, although treatment is needed regardless of fibrosis stage, Zepatier 50/100 mg tablets for 12 weeks is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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 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: The patient has requested authorization and coverage for Vraylar. A study reports cariprazine (brand name Vraylar) was significantly better than placebo at response in treating bipolar 1 disorder. Another study notes while cariprazine was generally well tolerated, there was a lack of significant improvement in depressive symptoms with adjunctive cariprazine and antidepressant treatment for patients with major depressive disorder. In this case, the patients diagnoses include both major depressive disorder and bipolar disorder. Given the provider recommended a medication regimen augmenting antidepressants with cariprazine and the patient has stabilized on this regimen, the requested medication is medically indicated. In this patients case, the medication Vraylar is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, Vraylar is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 55-year-old female enrollee has requested for a sacroiliac joint injection for treatment of her low back pain.  Findings:  Three physician reviewers found that the use of fluoroscopic guidance is appropriate as noted by Slipman and colleagues in their publication. The therapy was significantly more beneficial to her than alternative therapies
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested Xolair injections for treatment of the enrollees asthma.   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested medication. Xolair has been approved by the U.S. Food and Drug Administration (FDA) for use in patients who are 12 years of age or older and who have IgE levels less than 700. In the case of this patient, he is age 10 and has an IgE level in excess of 700. However, the use of Xolair is not contraindicated in a child with an IgE level greater than 700. In this case, the patient remains unstable despite an aggressive treatment regimen. While the patients pulmonary function tests have been reasonably normal the submitted clinical information documents that he has a history of frequent exacerbations requiring the use of rescue medications. All told, Xolair injections are medically necessary for the treatment of the patients medical condition. Therefore, the requested medication should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, hepatitis C is considered a serious systemic infection which causes substantial morbidity. Treatment is safe and effective, and can mitigate the serious consequences of this disease, and thus all patients, with the exception of those with life expectancy limited to less than 12 months due to non-related conditions, should be considered for treatment. This is a Level 1 recommendation from the AASLD/IDSA. Candidacy for treatment is limited mainly by the presence of contraindications to the available regimens which this patient does not have. As such, the medical necessity for Harvoni for 12 weeks has been established 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 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 45-year-old female enrollee has requested the prescription medication Provigil for the treatment of her depression. Findings:  The physician reviewer found that this patient has had ample trials of conventional antidepressants, such that Provigil can be appropriately deemed the supplement of choice. Her psychiatrist has detailed the previous medication regimens and the patients response in regard to depression and lethargy/inertia. The patient has responded well to Provigil and continued treatment should be supported.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested immediate release morphine sulfate pills 15 mg in a quantity of 300 pills per month for treatment of his chronic medical condition.  Findings:  The physician reviewer found that the American Pain Society published guidelines for the use of chronic opioid therapy includes recommendations regarding high-risk patients, which include consultation with a mental health or addiction specialist. There are some aberrant behaviors noted with this patient: macerating the extended-release preparations; losing count of how many tablets he used over the last twenty four hours, and; stating that he is severely addicted to opioids. This last statement, even though not confirmed by any of the clinical records, makes this patient an appropriate candidate to consult with an addiction specialist before resuming high dose opioid therapy for management of his chronic pain with either short or long-acting preparations. In addition, this consultation is needed to examine why this patient lost an analgesic effect to his dosage of opioids after being stable on them for a previously extended period of time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain. This patients initial clinical presentation was most consistent with migraine with no abnormal findings on examination or significant change in headache pattern described. Therefore, his initial presentation is consistent with Variant 4, which did not support an indication for initial computed tomography (CT) or MRI. However, the patient has repeated complaints of headache and multiple visits suggest Variant 7 presentation, chronic headache presenting with new features or increasing frequency. As a negative head CT scan is not the preferred imaging modality in the non-acute setting, this supports an indication for the requested MRI of the brain. The patient does describe worsening headache during the emergency department visit. The American College of Radiology (ACR) appropriateness criteria states that, further workup is indicated including neurologic imaging in patients for whom the frequency, severity, or character of headache changes in the setting of a prior history of benign headaches. The patients headache increased in severity, which is considered a red flag. Therefore, the requested MRI of the brain is medically necessary for 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 56-year-old male enrollee has requested reimbursement for emergency medical services for treatment of an emergency medical condition. Findings:  The physician reviewer found that According to the documentation submitted for review, the patient was admitted to the hospital through the emergency department due to significant deterioration of his condition with intractable back and lower extremity pain, and diminished ankle dorsiflexion and plantar flexion strength to 3+/5 requiring emergency surgery. The L5-S1 anterior lumbar interbody fusion performed is supported by evidence-based medical literature to address the nerve root compromise that would result in temporary intraoperative instability. Given the patients progressive neurologic deficits, the patient received emergency medical services for an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee has requested peripheral tibial nerve stimulation (PTNS) for treatment of her interstitial cystitis. Findings:  Three physician reviewers found that this patients history includes a diagnosis of interstitial cystitis and irritable bowel syndrome. The medical records do not however document symptoms of an overactive bladder, for which PTNS has been demonstrated to be effective. The available scientific data support the use of PTNS for patients with overactive bladder but not in cases of pelvic pain. Since the records do not support a diagnosis of overactive bladder, the requested therapy would be investigational in this patients clinical circumstance.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of her 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 51-year-old female enrollee has requested Celebrex for treatment of her back pain.  Findings:  The physician reviewer found that the patient has requested Celebrex to treat her inflammatory pain related to trochanteric bursitis and lumbar radiculopathy, post decompression surgery.  She failed to find relief with ibuprofen and is on Neurontin and Methadone.  The patient was previously treated with Celebrex 200mg per day and it had been efficacious for her, she has no contraindications to the medication and has a relative contraindication to traditional NSAIDS. Although, treatment with NSAIDs is appropriate therapy, the patient has already failed treatment with ibuprofen. Given her previous success with Celebrex, combined with a history of a gastroduodenal ulcer and inflammatory pain, it is appropriate to treat the patient with Celebrex at this time.  Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine and lumbar spine without dye for medical evaluation of his back pain.  Findings:  The physician reviewer found that the patient presents with a history of chronic pain syndrome and has undergone previous MRI scans of the lumbar spine as well as a computed tomography (CT) scan of the cervical spine. There is no evidence of a significant neurological deficit. Moreover, the patients physical examination reveals limited range of motion with diffuse tenderness. There is no evidence of a motor weakness or sensory deficit in the bilateral upper or lower extremities. There is also no evidence of the emergence of any red flags indicating serious spinal pathology. All told, the medical necessity for the requested MRI of the cervical spine and lumbar spine without dye has not been established.