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 Orthovisc (hyaluronan) injection services. Hyaluronic acid injection for osteoarthritic knee pain has become an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications and/or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individual patients. With long-term use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can all have serious systemic side effects and may not be reasonable treatment options for some patients. This patient reports consistent relief with hyaluronic acid injections. Given this support, the requested Orthovisc (hyaluronan) injection services is medically necessary for treatment of this patients bilateral osteoarthritis. 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.   Findings:  The physician reviewer found that according to the most recent 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 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 the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials.  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: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for atovaquone 750 mg/5 mL oral suspension. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature supporting atovaquone in this clinical setting. The patient presents for treatment of Babesia duncani infection. However, this patient has no evidence for Babesia infection. Babesia infection is an acute illness with fever, anemia, and fatigue, and is not a chronic infection. The primary organism is Babesia microti and duncani. Moreover, there is no evidence for Rocky Mountain spotted fever. The treatment for Babesia duncani is clindamycin and quinidine. Final Result: The reviewer 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 internal 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested specialized thyroid gene testing for evaluation of her thyroid follicular lesion. Two physician reviewers found that since the chances of cancer in this patients category was 10-30%, it was reasonable to submit the specimen for genetic analysis. The National Comprehensive Cancer Network (NCCN) guidelines support the Afirma Fine Needle Aspiration (FNA) genetic analysis as one option for immediate genetic testing in this clinical setting. The testing allows the patient and provider to be reassured regarding the patients chance of malignancy. If the result had been suspicious, the chances of malignancy would support an indication for surgery. Thus, the specialized thyroid gene testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. The records reviewed document that this patient presented status post fall from 20 feet onto a concrete floor. The patient was determined to have comminution of L1 vertebral body with retropulsion of the fragments into the spinal canal up to more than 50% of the canal. She underwent an open corpectomy of L1 through a thoracolumbar approach and T12 to L2 fusion with cage fixation. As noted in the medical literature, the average length of stay following a mini-open thoracolumbar corpectomy is 7.2 days versus 12.2 days for an open thoracolumbar corpectomy (Sulaiman, et al.). This patient was hospitalized for 14 days following the surgical intervention. It is acknowledged that this is 1.8 days longer than the average stay. However, in this case, due to the complexity of the injury including retropulsion of fragments into more than 50% of the spinal canal requiring two-level fusion, length of stay slightly beyond the expected average would be reasonable. Furthermore, the patient demonstrated acute psychosis during this hospitalization. In light of the foregoing, the inpatient hospitalization services were medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for interlaminar stabilization procedure utilizing the Coflex device (CPT 22867). Based on the records provided for review, this patient meets the criteria for surgical intervention. The records document that she has medically refractory low back pain and lumbar radiculopathy. Imaging has revealed an etiology for her symptoms in the form of a degenerative spondylolisthesis at L4-5 with moderate to severe lumbar stenosis. The patients provider has recommended a posterior decompression surgery with adjunctive placement of the Coflex interlaminar device. However, the documentation does not include standing and lumbar flexion/extension x-rays. If the patients grade 1 spondylolisthesis is not stable, then she is not a candidate for the requested procedure. Moreover, the records do not demonstrate that the patient has been evaluated for osteoporosis, which is a contraindication for use of the Coflex device. The two primary surgical interventions available to this patient include lumbar decompression alone and lumbar decompression with instrumented fusion. Limited data are available comparing lumbar decompression alone with decompression plus the Coflex device. Studies found similar outcomes, without substantial data to support improved outcomes with use of the Coflex device. All told, the requested interlaminar stabilization procedure utilizing the Coflex device (CPT 22867) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the requested interlaminar stabilization procedure utilizing the Coflex device (CPT 22867) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  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 neurological 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: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female with a long-term history of migraine headaches. She has now developed chronic migraine with daily mild to moderate headache and one to two severe, intractable migraines a month, which have required urgent care or an emergency room visit for parenteral medication. She has been evaluated by experienced headache specialists and has apparently had her rebound headaches addressed by her current provider. She has reportedly failed numerous medications including Depakote, Topamax, Neurontin, Inderal, and Pamelor. She responds poorly to triptans. She remains partially disabled because of her headaches. She is seeking authorization for Botox, which the Health Plan has denied.The patient has severe refractory and intractable chronic migraine. She has had full evaluations for other treatable causes with no findings. She has failed all standard preventive treatments. She does not appear to have rebound headaches. A trial of Botox is reasonable and likely to be more beneficial than any other available therapy. For this patient standard treatment would be two cycles of Botox with re-evaluation thereafter. If the patient has a significant response to Botox, consideration should be given to long-term treatment.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a sixteen year-old male who had an episode of syncope are requesting authorization of a CT angiography (CTA) to exclude a congenital coronary anomaly.  Reviewers Findings:  The three reviewing physicians found that CTA is the best test available and is superior to traditional angiography in determining and excluding anomalous coronary anatomy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for growth hormone therapy for treatment of his short stature. Findings:  The physician reviewer found that Arimidex and growth hormone therapy was initiated in April 2007, and the initial three months growth response rose from a subnormal 2.4 cm per year to 12 cm per year. This supported a putative diagnosis of partial growth hormone deficiency or lack of physiological growth hormone secretion. No MRI of the brain appears to have been done, despite a history of chronic headaches.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that Per American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, treatment-naive patients with HCV genotype 1a are recommended for treatment with a daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. However, the effectiveness of Harvoni in patients who are treatment naive and non-cirrhotic is the same with 8 weeks and 12 weeks of Harvoni in patients who have a baseline HCV RNA levels below 6 million IU/mL. Therefore, Harvoni is medically necessary for 8 weeks in this treatment-naive patient with HCV and a viral load of less than 6 million.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old female with a body mass index (BMI) of 37.5 and multiple comorbid conditions including diabetes mellitus and hypertension. She has undergone a psychological evaluation and received clearance for weight loss surgery. The patient indicates that she has researched all of the surgical procedures and has selected the duodenal switch operation for treatment of her obesity. The Health Plan has denied coverage for the duodenal switch procedure asserting that this surgical procedure is not medically necessary for treatment of the patients condition.With a BMI of 37.5 and significant co-morbid conditions, the patient is an appropriate candidate for surgical intervention to treat her morbid obesity. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Furthermore, there is a large body of scientific evidence that shows superior short and long-term outcomes with the duodenal switch procedure when compared to the gastric bypass or the lap band procedure. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested a Tennant Biomodulator for treatment of her cervicocranial syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  There is a lack of published high-grade evidence to support the efficacy of the Tennant Biomodulator in this clinical setting.  The medical records noted a history of neck and upper back pain, and the provider noted the diagnosis of cervicocranial syndrome.  The current medical literature has not demonstrated the effectiveness of the device at issue.  The literature has not established the efficacy of electrotherapy modalities in the setting of cervicogenic pain.  No significant clinical improvement beyond a placebo effect would have been expected.  All told, the Tennant Biomodulator provided on on the said date was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) procedure for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to the TMS treatment recommendations by researchers The standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The article suggested that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient had already utilized this additional time frame.  Moreover, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness. Further, there is a lack of evidence in the literature to suggest that the patients marginal improvement was likely due to the additional TMS sessions, as the patients daily cannabis use may have been contributing to the suboptimal response. In addition, the patient was neither prescribed antidepressant medication nor active in psychotherapy at the time of treatment with TMS, which represented first-line interventions in the treatment armamentarium for major depressive disorder. 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 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

The parent of a 16-year-old female enrollee has requested residential treatment for the treatment of the enrollees panic disorder without agoraphobia, polysubstance abuse and major depressive disorder. Findings:  The physician reviewer found that she required 24/7 professional supervision in a structured environment. This could not be accomplished at any lesser level of care. When discharged earlier, she clearly decompensated and endangered her life. The patient was demonstrating a pattern of severe impairment of psychosocial function. Of note, the patient was unable to attend school due to her psychopathology. This patient required residential care for the period at issue. Any attempt to provide lesser level care could have compromised the patients safety.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested the prescription medication Restasis for the treatment of her ocular rosacea. Findings:  The physician reviewer found that although the patient has tried standard first line therapies for her condition, she continues to be plagued by symptoms.  Second line therapy would include Maxitrol and Pandel.  These are not long-term solutions, but they should be tried before Restasis.  Restasis in this setting would be considered investigational at this time, although it is showing some promising results in on-going clinical trials.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the paper by Myers and colleagues is frequently cited in the autistic literature as a definitive source of the evaluation and treatment of autistic children. The authors report their findings suggest patients with ASD can develop useful speech. The authors cautioned that patients can benefit from therapy despite chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores. In addition, Turner and colleagues conducted a controlled study and concluded that autistic children who received speech therapy had far greater communication skills than similar patients who were untreated. Similarly, the American Speech-Language Hearing Association (ASHA) Ad Hoc Committee on Autism Spectrum Disorders found that children with autism can benefit from speech therapy. In sum, speech therapy is medically indicated and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female has requested Colaris testing for evaluation of her genetic risk for colon cancer.   Findings:  Three physician reviewers found that the patient has a personal history of colon polyps. The records indicate the patient also has a mother and sister who had endometrial cancer at ages 55 and 64, respectively. The patient has requested that she be evaluated for Lynch syndrome to determine whether she has a genetic predisposition with Colaris testing. The National Comprehensive Cancer Network (NCCN) guidelines allow testing for patients with known cancers and multiple familial evidence of cancer in specific circumstances. However, this patient does not meet the criteria for testing. Further, the patient does not fit into a category of patients who should be evaluated for Lynch syndrome using the Revised Bethesda Guidelines. She has no personal history of cancer and there are no synchronous, or metachronous cancers. Based on the lack of scientific data demonstrating improved health outcomes when using the Colaris testing in this patient population, the requested testing is not supported as likely to be more beneficial than standard therapies in evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested Nuvigil for treatment of his depression.  Findings:  The physician reviewer found that there are few studies to support the use of Nuvigil in depression or bipolar disorder.  However, Nuvigil (armodafinil) is the active R-enantiomer of the racemic medication Provigil (modafinil) and there is a strong evidence base to support the use of Provigil in depression. Results of this pooled analysis provide further evidence suggesting that modafinil is an effective and well-tolerated augmentation therapy for partial responders to SSRI therapy, particularly when patients continue to experience fatigue and excessive sleepiness (Fava and colleagues). Psychostimulants warrant consideration as potential therapeutic agents in specific patient subgroups (Orr and Taylor). This patient appears to be in a subgroup of patients who have failed multiple medications and have sleep complications due to medications, depressive symptoms or hypomania associated with bipolar disorder. He is now functioning well on his current medication regimen which includes Nuvigil. Continuation of Nuvigil is medically sound in this situation and should be authorized.