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 Wegovy.Findings: A study indicates that obesity is associated with increased risk of numerous chronic diseases including type 2 diabetes (T2D), hypertension, and cardiovascular disease. Additionally, the study states, Weight loss of 510% results in improvements in cardiometabolic risk factors. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Another study states that semaglutide promotes weight loss by reducing energy intake, increasing satiety and satiation, and reducing hunger, as well as enhancing glycemic control. Another study found, In adults with obesity, once-weekly semaglutide 2.4 mg suppressed appetite, improved control of eating, and reduced food cravings, ad libitum energy intake and body weight versus placebo. In the study, body weight was reduced by 9.9% (10.4 kg) from baseline to week 20, in the absence of structured dietary and exercise intervention, compared with almost no change in the placebo group. In this case, the patient has a high BMI. Records reflect that the patient has tried and failed other medications used to manage weight gain. Therefore, Wegovy is medically necessary for treatment of the 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: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested hepatic transcatheter arterial chemoembolization for treatment of his metastatic gastrointestinal stromal tumor. Findings:  Three physician reviewers found that this patient has developed refractory and progressive liver disease and is currently receiving third-line medical therapy.  Ideally, surgical resection would be mainstay of treatment.  However, he was deemed not to be a surgical candidate.  Radiofrequency ablation is not recommended with lesions over 5 cm in size.  Chemoembolization is a recommended and often performed procedure for metastatic lesions to liver.   Although not commonly performed, success has been reported with embolization of metastatic gastrointestinal stromal tumors. The references demonstrate improved outcomes versus medical therapy alone. All told, hepatic transcatheter arterial chemoembolization is likely to be the most beneficial treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested laser therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. This patient has tried and failed therapy with topical ketoconazole cream. There is no medical documentation of the patient having tried and failed or demonstrating a contraindication to treatment with oral antifungal agents, such as terbinafine.  Terbinafine is considered to be a first-line agent in the treatment of onychomycosis.  Use of laser treatments for onychomycosis continues to be evaluated, but is not considered to be standard of care.  Per the submitted documentation, the patient had not tried and failed standard oral therapies.  Thus, laser therapy was not likely to have been more effective than other treatment alternatives.Final Result: Three reviewers determined that the services at 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: All three physician reviewers are board certified in dermatology 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: The enrollee has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan has denied the request as not medically necessary.Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.A review of current literature pertaining to viscosupplementation reveals mixed results. Research studies found that intra-articular hyaluronic acid (HA) injections provide a moderate symptomatic benefit to knee osteoarthritis without major safety concerns. Researchers performed a meta-analysis of double-blinded, sham-controlled trials with at least 60 enrollees and concluded that the evidence did not show clinically important differences of HA over placebo. Researchers concluded that viscosupplementation increased functional scores in enrollees with severe osteoarthritis of the knee, especially within three months of injection. However, it was not superior to triamcinolone. In light of the foregoing, viscosupplementation is recommended in enrollees with a history of lasting benefit from prior injections and in carefully selected cases where conservative modalities have failed and the remaining treatment options are limited. In this case, there is known benefit from prior injections, and the options are limited, with the alternative being bilateral total knee arthroplasties. As such, the request for Euflexxa injections in both knees are medically necessary for treatment of this enrollees knee osteoarthritis.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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

The patient has requested reimbursement and prospective authorization and coverage for a hospital-grade breast pump. The records provided for review support a diagnosis of granulomatous mastitis. The peer-reviewed medical literature discusses the lack of a consensus regarding optimal treatment for this condition. In order to reduce the patients risk of lactation mastitis, it is beneficial for the patient to use the highest quality breast pump available during lactation. Providing a hospital-grade breast pump to lower the patients risk for worsening of her condition is appropriate and supported by the current medical literature. All told, the hospital-grade breast pump was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 obstetrics and gynecology 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 bilateral knee Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees bilateral knee osteoarthritis. At issue in this case is whether the requested bilateral knee Euflexxa injections are medically necessary for treatment of the patients medical condition.A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended; as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least 3 months; including failure to respond adequately to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement and more effective than corticosteroid injections. In this case, the patient has persistent bilateral knee pain. Significant functional limitations are noted in walking and exercise. Clinical examination findings are consistent with x-ray evidence of bilateral knee tricompartmental osteoarthritis, bone-on-bone in the medial compartment. The enrollee is required to lose weight prior to undergoing total knee replacement and is considering bariatric surgery. The enrollee has failed to respond adequately to other conservative treatment including physical therapy; home exercise program; non-steroidal anti-inflammatory drugs (NSAIDs); and corticosteroid injections. Therefore, the requested Euflexxa injections for the bilateral knees are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an acrylic herbst oral appliance for treatment of his medical condition.  Findings:  The physician reviewer found that based upon the submitted documentation, the medical necessity of the acrylic herbst oral appliance has not been established. Per the submitted documentation, the patient was found to have a normal AHI score.  The patient also presented with an Epworth Sleepiness score which was also normal. Moreover, there is no documentation of daytime hypersomnia. The record does indicate there was a postural component and it was recommended that the patient should avoid supine sleep. The recommended treatment for those with significant postural obstructive sleep apnea (OSA) with an AHI of 15 or higher, is with a vest that has a ball in the back to preclude supine sleep. The patients medical records do not indicate he has clinically significant OSA. All told, the oral device at issue was not medically necessary for treatment of the patients medical condition.    Final Result: The reviewer determined that the device at issue was 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 pulmonary disease 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 46-year-old female enrollee has requested a laparoscopic partial hysterectomy for the treatment of her menorrhagia. Findings:  The physician reviewer found that this patient has debilitating menorrhagia and menstrual pain despite using oral contraceptives. She has already attempted hormonal treatment for her condition. The patient has also had an endometrial evaluation via biopsy showing weakly proliferative phase endometrium. Given this result, and the finding of a very thin endometrium on ultrasound, a hysteroscopy or a dilation and curettage would not be useful, and would only add surgical risk without anticipated benefit if performed in this case. As noted in the American College of Obstetricians and Gynecologists (ACOG) Guidelines for Womens Healthcare, women with anovulatory uterine bleeding who have failed medical therapy and no longer desire future childbearing are candidates for endometrial ablation or hysterectomy. Although endometrial ablation is an option that could be pursued for treatment of the patients heavy periods, it is not likely to be as effective for treatment of her menstrual pain as partial hysterectomy. In this patients case, a laparoscopic partial hysterectomy is more appropriate than the alternatives specified by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee requested a continuous passive motion (CPM) for medical treatment of her status right knee arthroplasty.  Findings:  The physician reviewer found that the medical literature does not support the services at issue in this clinical setting. Harvey and colleagues evaluated the effectiveness of continuous passive motion following total knee arthroplasty in people with arthritis. The authors concluded, The effects of continuous passive motion on knee range of motion are too small to justify its use. Furthermore, the documentation submitted for review did not indicate extenuating circumstances or exceptional factors for which the CPM should be considered. The patients diagnoses at the time of surgery were noted as hip pain, hypertension, limb pain, lumbar radiculopathy, and osteoarthritis of the knee.  None of the conditions noted warrant the use of a CPM device. All told, the use of the CPM device was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested the prescription medication Rozerem for the treatment of her insomnia. Findings:  The physician reviewer found that Rozerem has a unique mechanism of action, different than that of the numerous other agents tried in this patients case. Retrying any of the other agents is not medically indicated, even if they have not been tried in the previous 180 days. Because the patient has failed therapy with other hypnotics, the patient has reported benefit with the use of Rozerem and there is no evidence to suggest a need to attempt trials of additional hypnotics.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 28-year-old female with an apparent diagnosis of bipolar disorder. Her current medications include Risperdal, Effexor, Trileptal, Lamictal and Ambien. She has requested coverage for Provigil for daytime sedation. She reports that she has had good results with the use of Provigil to date. The Health Plan has denied coverage for Provigil citing a lack of medical necessity.The patient reports experiencing daytime fatigue, some of which may be attributable to her current medications, which can produce sedation. Of note, is her use of Ambien for treatment of insomnia. This drug can contribute to daytime fatigue when used on a regular basis. The use of Provigil to counteract the side effects of other medications is not within the standard of care. Therefore, I have determined the medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks. The patient has been diagnosed with hepatitis C. The American Association on the Study of Liver Diseases and Infectious Diseases Society of America reported, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. The authors noted that a daily fixed-dose combination of ledipasvir (90 mg)/sofobuvir (400 mg) for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 1b without cirrhosis. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Harvoni 90-400 mg tablets for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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: The patients parent has requested authorization and coverage for Absorica LD. The records provided for review document that this patients acne vulgaris has failed to substantially improve despite treatment with minocycline. Thus, treatment with systemic isotretinoin is a reasonable option for the patient. Treatment of acne follows a stepwise escalation, with isotretinoin being one of the more effective systemic treatments (Eichenfeld, et al.). However, the records fail to support treatment with Absorica LD in lieu of another formulation of isotretinoin. Absorica LD is a micronized formulation of isotretinoin. On review of the medical literature, there is a lack of comparative studies demonstrating superior efficacy of Absorica LD rather than other preparations in the treatment of patients with acne vulgaris. Moreover, this patients records do not document adequate trial and failure, or intolerance to, treatment with a non-lidose, non-micronized formulation of isotretinoin. For these reasons, the requested Absorica LD is not medically necessary for treatment of this patient.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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee is requesting services for one-on-one psychologist visist once a week for two to three months. Findings: The physician reviewer found that there is support in the documentation for the requested services in this clinical setting. In general, the standard of care for treatment of patients in crisis require frequent therapy sessions. In this case, the patient was recently diagnosed with bipolar type 1. The patient was hospitalized due to suicidal ideation and after a manic episode. Accepting the diagnosis of bipolar and staying compliant with treatment is a challenge for many newly diagnosed patients with bipolar type 1 disorder. The patient continued to be anxious and continued to have difficulty with school and family. The patient is requesting weekly therapy sessions for two to three months to help him through this transition period. Based on the records provided, this patient is likely to benefit from weekly therapy sessions for up to three months to help him through this transition period and to stay compliant with treatment. Therefore, one-on-one psychologist visit once a week for two to three months are medically necessary for treatment of this patients medical condition. Given these findings, the requested services are medically necessary for treatment of this patients medical condition. 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 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 40-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  There is adequate support for the requested services in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of patients with depression.  In this case, the patient is experiencing an acute major depressive episode that is causing significant morbidity and functional impairment.  He has pursued other standard therapies used to combat depression.  Considering the medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, TMS is an appropriate treatment.  All told, TMS therapy is medically indicated for the treatment of this patient.