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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for hyaluronan injections for osteoarthritis of both knees. Symptoms include pain, swelling, clicking, and painful range of motion. She has difficulty walking and using the stairs. Her symptoms are exacerbated by kneeling and squatting. Past treatments include bracing, icing, physical therapy, non-steroidal anti-inflammatories, cortisone injections, and a knee aspiration. A magnetic resonance imaging scan of the left knee showed osteoarthritis and a lateral meniscal tear. She was assessed by two different orthopedists, one who recommended surgery and one who did not. The enrollee obtained a third opinion. This orthopedist discussed treatment options, including hyaluronan injections, arthroscopic surgery, and joint replacement. The current treating orthopedist has requested hyaluronan, one injection per knee, once per week, for three weeks. The enrollee is requesting hyaluronan injections for both knees instead of surgery, because the treatment plan put in place by her orthopedist was to try everything else possible before surgery. The enrollee suffers from bilateral knee osteoarthritis, as indicated in a radiographic study but is not a total knee replacement candidate at this time. Viscosupplementation as pain management is the next logical choice of management. Literature indicates repeated treatments with intra-articular hyaluronic acid injections are an effective and safe treatment for knee osteoarthritis. Repeated treatments were shown to maintain or improve pain reduction without additional safety risks. Hyaluronic acid injection has become a viable treatment option for the non-operative management of enrollees with knee osteoarthritis. Use of this treatment for managing osteoarthritis knee pain has been well documented in research; both cellular studies and clinical investigations. Research has demonstrated improvement to the local biology within the knee with the use of hyaluronic acid injections, resulting in decreased pain and improved function. Literature notes hyaluronic acid is effective due to its many methods of actions, including lubrication and anti-inflammatory effects.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested sacroiliac joint fusion for treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  Previously, she has undergone a multilevel laminectomy and fusion procedure at L3-S1.  Per the medical records, sacroiliac joint radiofrequency ablation did not provide relief.  In this case, the diagnosis of sacroiliac degenerative disease is not well-supported by the documentation provided, and the requested services are not likely to relieve this patients chronic back pain.  There is a lack of support for the requested services in this case.  Thus, the requested sacroiliac joint fusion is not likely to be of greater benefit than other options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 28 imiquimod 5% cream packets for 28 days.Imiquimod (Aldara) 5% cream has been  approved by the U.S. Food and Drug Administration and is indicated for the treatment of external genital and perianal warts/condyloma acuminata in individuals 12 years old and older. A systematic review of randomized trials by Grillo-Ardila  and colleagues found this drug superior to placebo for achieving complete and partial regression of anogenital warts. According to Komericki and colleagues, clearance rates from randomized trials for imiquimod 5% cream range from 35 to 75 percent, and recurrence rates range from 6 to 26 percent. In this case, a physical examination revealed that the patient has perianal warts. The medical literature indicates that imiquimod is a safe and effective treatment for perianal warts. Therefore, 28 imiquimod 5% cream packets for 28 days are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the medication is 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested hip resurfacing arthroplasty with the Birmingham Hip Resurfacing System for treatment of his osteoarthritis.  Findings:  Two physician reviewers found that the patient in this instance has advanced degenerative changes of the hip. While resurfacing arthroplasties have been utilized in hip surgery for years, the technology of metal-on-metal implants continues to evolve. There is concern pertaining to ion release and durability. It is not known whether the resurfacing system will have the longevity of the standard/traditional total hip arthroplasty. There is no long-term data demonstrating the safety and efficacy of metal-on-metal resurfacing and there are no well controlled peer-reviewed studies demonstrating it is superior to traditional replacement.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 22-month-old female enrollee has requested speech therapy services for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this nearly two-year-old female patient has no speech. She was reported to have two words at 13 months by her mother, but when evaluated at the age of 17 months she had no language. The articles by Law and colleagues and Goorhuis-Brouwer and Kniff both report the effectiveness of language therapy in speech delayed children. Goorhaus-Brouwer, further reported that speech therapy aids the development of speech in patients who are developmentally delayed. Additionally, children with macrocephaly have a higher incidence of neurological delays than children who are normocephalic. All told, this patient will benefit medically from speech therapy. As she is nearly two-years-old, she is an appropriate candidate for initiation of speech therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollee, who presented for a breast examination. Findings:  The 3 physician reviewers found that the patient is a female who was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination. The current images were compared to prior mammograms. No interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Benign appearing nodularity and scattered calcifications were seen.  Her breasts were described as being very dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as being very dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Upheld

A 46-year-old female  has requested approval for breast cancer surgery to be performed by a breast cancer surgical oncologist versus a general surgeon, and breast cancer surgery in a treatment facility that specializes in cancer treatment versus a standard surgical environment for treatment of her right breast carcinoma.   Findings:  The physician reviewer found that currently, there is inadequate data that breast cancer patients who are treated by breast surgeons experience superior outcomes when compared with treatment provided by general surgeons. Further, there is no indication that care provided in specialty centers is superior to that provided in general practices. One of the four surgeons offered by the Health Plan is a trained surgical oncologist, and the other three providers are general surgeons. Certification by the American Board of Surgery (ABS) includes assessment of competency in breast cancer care. In addition, there is nothing about this patient that is unusual or complex other than a second adjacent benign lesion that should be excised at the same time as the definitive surgery for the DCIS.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services (RTC). The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder, generalized anxiety disorder and social anxiety disorder.The patient was admitted to the residential treatment center due to problems with anxiety. The patient was noted to show cooperative behaviors. The patient expressed how their relationship with family had improved. The patients main issue that continued was unhappiness with how peers were acting in the residential treatment center. The patient did not have active suicidal or homicidal ideation or psychosis during this timeframe.The patient denied a history of substance use. The patient was noted to have migraine headaches as well as celiac disease and these were not mentioned as problems during this timeframe.  The patient was noted to scratch herself during times of stress. The patient did not display aggression towards peers or staff during this timeframe. The patients family was involved with treatment. The records did not document any severe mood or anxiety symptoms or any serious behavioral issues.   The patients presentation resulted in a composite score of 17.  This score correlates with a treatment intensity level of three which correlates with a level of Intensive Outpatient Services.  Therefore, the requested residential treatment center services at issue were not medically necessary.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty 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: Overturned

A 56-year-old female enrollee has requested lumbar spine laminectomy and decompression of the L4-5 spinal level for treatment of her low back pain. Findings:  The physician reviewer found that in this patients case, there is adequate documentation of failed conservative care. While the patient had not undergone a trial of epidural steroid injections, a review of the literature demonstrates that at best, there is short-term efficacy from epidural blocks with no documented long-term efficacy. The epidural blocks, in addition to having only short-term benefit, are also invasive procedures with a higher level of risk than other conservative therapies such as physical therapy and chiropractic care. These potential complications include drug reactions, fat necrosis and iatrogenic nerve root injury. A primary goal of conservative non-surgical treatment has been met in this patient - that goal being the passage of time, giving the patient the opportunity to experience the beneficial effects of a cyclical pattern of exacerbations and remissions characteristic of chronic low back pain. There is sufficient documentation in the submitted records of both the persistence and worsening of the patients symptoms despite conservative treatment, and the anatomical findings documented on x-ray and MRI justify the need for the proposed surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Mavyret 100/40mg as three tablets daily for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype three patients should be treated with Mavyret as three tablets daily for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95 percent cure rate with eight weeks of treatment. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret as three tablets daily for eight 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: Upheld

A 58-year-old female enrollee has requested Beta irradiation for the treatment of her left eye pterygium. Findings:  The physician reviewer found that the patient is requesting Beta irradiation as primary treatment of her pterygium in her left eye. The patients treating provider, an ophthalmologist, recommended surgical excision with conjunctival autograft. This recommendation is the standard of care within the ophthalmology community for treatment of a primary pterygium in a patient that is not at significant risk for recurrence. Based on the information provided by the treating provider, this patient is not at high risk of recurrence as he indicated a 90% likelihood of success. In high risk patients, the standard of care is excision with conjunctival autograft in addition to intra-operative or post-operative mitomycin C. Beta irradiation is an adjuvant treatment for patients after surgical excision of a pterygium to reduce the risk of recurrence. However, the risk profile of Beta irradiation is greater than newer anti-metabolites such as mitomycin C and thus, Beta irradiation is no longer considered the standard of care, even for adjuvant treatment after pterygium excision.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Magnetic resonance imaging (MRI) of the head and magnetic resonance angiography (MRA) of the head. Findings: The patient has a history of facial and upper extremity numbness or tingling. As noted in the medical literature, this patients symptoms are concerning for transient ischemic attack (TIA). Per a study, patients with TIA or stroke are at increased risk of recurrent stroke. Treatment protocols include thorough evaluation and therapies focused on reducing the patients risk of recurrent stroke. Brain imaging with MRI is indicated for all patients with suspected TIA. It is critical to establish whether there is an obstructive lesion in an artery supplying the affected territory. Noninvasive options for evaluation of large vessel occlusive disease include MRA. In this patients clinical setting, the MRI and MRA were indicated for diagnostic purposes and to help guide treatment. All told, the MRI of the head and MRA of the head were medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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 neurology with subspecialty certification in vascular 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  For treatment-naive patients with hepatitis C, genotype 6 infection, the guidelines recommend Harvoni.  For these reasons, Harvoni is medically indicated 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for tobramycin 300 mg/5 mL inhalation solution/powder. Based on the available information, the requested tobramycin 300 mg/5 mL inhalation solution/powder is medically necessary for the management of this patients condition. Loebinger and colleagues reported that tobramycin significantly reduced the P. aeruginosa sputum density from baseline to day 29 versus placebo in a dose-dependent manner. Moreover, the European Respiratory Society (ERS) guidelines support a therapeutic trial of inhaled antibiotics for patients with P. aeruginosa in their sputum who are experiencing significant morbidity from acute exacerbations (Polverino, et al.). The records provided for review document that this patient has pseudomonas in sputum, and has demonstrated significant morbidity based on recurrent chest infections requiring IV antibiotics despite maximal medical management with an aggressive mucous clearance program. Given this support, the requested tobramycin 300 mg/5 mL inhalation solution/powder is 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.