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

The patient is a 71-year-old male who has requested authorization and coverage for Byetta. He has had type II diabetes for more than 10 years. He has neuropathy, renal impairment and retinopathy. The patients hemoglobin A1c dropped from 7.2% to 6.5% in June 2005. In September 2005 he was started on Byetta 5mcg twice daily. In January 2006 the dose was increased to 10mcg twice a day. He has lost 4 pounds since starting Byetta. According to the physicians notes in February 2006, the patients blood glucose values have not improved. The patient is currently using Byetta 10mcg twice daily, glipizide 3.5mg in the morning and 5mg with dinner and Lantus insulin 20 units at bedtime. The patients physician states that the patient has substantial insulin resistance.At issue is whether Byetta is medically necessary for treatment of the patients medical condition.In clinical trials, Byetta was indicated only in patients who had a hemoglobin A1c over 7%. This patient had a hemoglobin A1c of 6.5% at the time of initiation of Byetta. Thus, he was at goal according to the guidelines of the American Association of Clinical Endocrinologists and the American Diabetes Association. His blood sugars have not substantially improved since being placed on Byetta. Byetta improves postprandial blood glucose and does not improve insulin resistance. This patient appears to have insulin resistance. For these reasons, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested for the transcranial magnetic stimulation (TMS) therapy for treatment of her major depression. Findings:  Three physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  This patient had been treated with multiple available standard therapies without improvement in symptoms and her acute hospitalization evidenced that the patient was experiencing active suicidal ideation and planning, making it imperative that she receive additional psychiatric treatment. Thus, all told, the TMS therapy at issue was likely to be more beneficial than other standard therapies available for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old male with the diagnosis of Peyronies disease. This has reportedly been present for eighteen months and has been associated with erectile dysfunction. In his report from October 2005, the urologist described the patients symptoms as reduced (penile) rigidity along with some penile shortening but no significant curvature. The patient is reported as still being able to achieve vaginal penetration and his libido is described as healthy. Physical examination at that time revealed fairly diffuse Peyronies plaque on the dorsal and lateral aspect of the mid penis.The patients urologist recommended transdermal Verapamil gel in order to avoid surgery. In addition, Cialis has been recommended for the patient.At issue is whether the requested medications are medically necessary for treatment of the patients medical condition.This patient has been diagnosed as having Peyronies disease. His primary, medically treatable problem associated with this condition is erectile dysfunction. Cialis, an oral PDE-5 inhibiting medication, is a medically appropriate and indicated treatment for the patients erectile dysfunction and should be authorized.As for the treatment of the underlying Peyronies disease with transdermal Verapamil gel, there is no significant, peer-reviewed, objective, documented literature currently available indicating that this use is efficacious. There are other treatments (short of surgery) available for treatment of Peyronies disease. Depending upon the patients current status, oral treatments such as vitamin E or Potaba may be appropriate as well as intra-lesional injection therapy with steroids. At this time there is no evidence that transdermal Verapamil gel is likely to result in an improved clinical outcome in this case. Based upon the information set forth above, I have determined that although Verapamil gel is not medically necessary for treatment of the patients medical condition, Cialis is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial of the requested medications should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee requested the fentanyl patch for medical treatment of his chronic headaches. Findings:  The physician reviewer found that based on the available medical literature, there is no role for chronic narcotics in the management of chronic headache disorders. Moreover, it has been demonstrated that chronic narcotic use causes chronic headache and opiate withdraw as well (De Marinis, et al; Creach, et al). This is known as medication overuse headache. For these reasons, this patient should undergo treatment with the goal of narcotic elimination (Scher, et al). All told, the requested fentanyl patch is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested a Neuromonics Tinnitus Device (and related services) for the treatment of his tinnitus. Findings:  Two physician reviewers found that as of yet, there is no truly effective treatment option for tinnitus. The current literature does not contain enough quantitative support for the use of this device to be taken out of the experimental/investigational category. Neuromonics announced publication of its first clinical study evaluating this therapy when compared to relevant control groups. Fifty tinnitus patients were randomly assigned to treatment groups, the other two groups being those receiving broad band stimulation and those given no stimulation. After 6 months, the Neuromonics group, which would most likely be a third of the patient study population, showed self reported improvement of 66%. The third clinical trial contains 35 patients randomized to 2 treatment groups. It is not mentioned whether these studies were blinded, and most results depended on subjective patient self reporting. As such, although the Neuromonics device shows some promise, further studies are recommended before this treatment is deemed standard of practice and not experimental. Even though current standard therapy for tinnitus is poor, the current amount of data available does not demonstrate that the Neuromonics device was likely to be more beneficial for the treatment of tinnitus than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old male with dyslipidemia who has been treated simultaneously with Vytorin (simvastatin and ezetimibe) and niacin. His provider has recommended that Omacor be added to his medication regimen and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.There is no clinical support for the argument that gemfibrozil is contraindicated due to elevated transaminases. Omega 3 fatty acids are not generally considered first-line therapy for dyslipidemia and standard therapies are likely to be effective for treatment of the patients condition. The documentation provided does not indicate other therapies have been tried and failed. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Aciphex for the treatment of his acid reflux. Findings:  The physician reviewer found that proton pumps inhibitors continue to be the backbone of therapy for acid suppression, and continue to be the standard of therapy for the treatment of GERD. All PPIs decrease acid secretion by inhibiting parietal cell proton pumps. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. Inter-patient variability of the efficacy is seen most with esomerazole (Nexium) and pantoprazole (Protonix), and least with lansoprazole (Prevacid) and rabeprazole (Aciphex). The patient in question has not tried Protonix and Prevacid. He should be given eight-week trials of Protonix and Prevacid before pursuing coverage for a non-formulary PPI (Aciphex). If there is documented evidence that the patient fails to respond to Protonix and Prevacid, his request for Aciphex should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a consultation with a gastroenterologist specialist.The most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommend procedural evaluation of bleeding, which is not documented in this case, and Gastroenterology consultation is warranted to determine if this is appropriate (ASGE Standards of Practice Committee, et al.). Additionally, Mott and colleagues recommend evaluation for alternative causes of symptoms, including fissure and inflammatory bowel disease. Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Gastroenterology (ACG) recommend workup for other causes of symptoms and various procedural interventions for hemorrhoids which do not respond to conservative medical therapy. ASCRS and ACG guidelines also support evaluation for other causes of symptoms such as anal pain and rectal bleeding.In this case, the patient is suspected to have hemorrhoid disease as a cause for anal pain and bleeding, although this has been ongoing for months without improvement with topical therapy, and multiple evaluations by multiple providers have not elucidated a cause for the patients symptoms or an effective treatment. The patient may have other pathology, such as fissure or inflammatory bowel disease, and evaluation for these would be consistent with evidence-based guidelines. The patient has had longstanding symptoms and evaluation by multiple practitioners without a cause for symptoms. Under these circumstances, the requested consultation with a gastroenterologist specialist is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 49-year-old male enrollee has requested physical therapy services with an out-of-network provider for treatment of his status post microdiscectomy. Findings:  The physician reviewer found that in the case under review, the patients S1 radicular symptoms flare quickly in the sitting position, and he was unable to tolerate the travel time to an in-network physical therapy provider. In order to benefit from the prescribed treatment plan, it is medically necessary that he receive this therapy in closer proximity to his home.  This service is only available from an out-of-network provider.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening studies has gained popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  This patient was found to have extremely dense breast tissue on her mammogram, and the addition of tomosynthesis has proven especially valuable in this setting due to the tomographic qualities of tomosynthesis.  All told, the addition of breast tomosynthesis to the screening study was likely to be more beneficial to the patient than digital mammography alone. Final Result: Three 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: All three reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Roux-en-Y gastric bypass procedure. The enrollee has diagnoses of systemic lupus erythematosus (SLE), morbid obesity, obstructive sleep apnea, hypertension, and asthma. Findings:She was evaluated for bariatric surgery due to her body mass index (BMI) of 43. She underwent a gastric sleeve procedure. Her weight at that time was 277 lbs. A follow-up visit demonstrated a 79-lb. weight loss. She reported attempts to adhere to dietary and exercise routines, but other physical maladies had limited her exercise abilities and her weight had increased to 230.5 lbs. Her physician began a weight-loss regimen that consisted of a 1200-calorie-per-day dietary modification, instructions to engage in 30 minutes of physical activity three times per week, and the addition of Phentermine, an appetite suppressant, to her medication regimen. A polysomnogram did not reveal evidence of obstructive sleep apnea. The dietitians report from recommended dietary changes. BMI at this time was 41.03. Her primary care physician indicated the enrollees weight had trended up from 235 lbs. to 251 lbs. and her co-morbidities would improve with weight loss. Her BMI was 40.67. Non-compliance with the Contrave regimen was reported. She had multiple joint pains with significant low back and knee pain, and stress fractures of the spine. Follow-up with her bariatric surgeon was recommended, as well as the need for permanent lifestyle changes and strict adherence to her prescribed postoperative diet. Based on review of the records, there is not sufficient evidence of compliance to post-operative dietary and lifestyle modifications following the enrollees initial sleeve procedure and she does not have any related post-procedure complications. According to the medical literature,  adherence to dietary, exercise and lifestyle modifications post-operatively is one of the key factors related to a successful procedure. The primary reasons for conversion to Roux-en-Y are either an anastomotic leak, or the onset or worsening of gastroesophageal reflux disease. The records do not show there is a technical complication of the current sleeve gastrectomy requiring revision or conversion into a Roux-en-Y gastric bypass. Therefore, the Roux-en-Y gastric bypass procedure is not medically necessary for treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections to both knees.Hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis that is significantly symptomatic who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the current medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. In this case, the patient presented with increasing left anteromedial knee pain and right knee mild swelling and tenderness. Clinical examination findings documented functional range of motion with crepitus. There was radiographic evidence of early osteoarthritic changes with small osteophytes appearing medial and laterally. She had reportedly failed to achieve adequate improvement with rest, physical therapy, home exercise program, and corticosteroid injections. The records noted that prior Synvisc injections to the left knee did not provide significant benefit. A recent right knee magnetic resonance imaging demonstrated evidence of right knee osteoarthritic changes, severe in the medial compartment. Current evidence-based criteria have been met for the requested Synvisc injections to the right knee. There is no documentation of significant improvement in symptoms for six months or more following Synvisc injection to the left knee to support repeat injections. Therefore, Synvisc injections to the right knee are medically necessary for the treatment of this patient. The medical necessity of Synvisc injections to the left knee has not been established. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 50-year-old female enrollee has requested the Exogen 4000 Ultrasonic Bone Stimulator for the treatment of her fractures. Findings:  Two physician reviewers found that this patients fractured third metatarsal failed to heal after over six weeks of immobilization. She is also osteopenic, which is a risk factor for bone healing. The articles demonstrate statistically significant bone healing capabilities with use of the device at issue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: male enrollee has requested authorization and coverage for nusinersen (Spinraza) for treatment of the enrollees spinal muscular atrophy (SMA) III. Findings:  The physician reviewer found that Spinraza is a modified antisense oligonucleotide (a synthetic genetic material) that binds to a specific sequence in the intron downstream of exon 7 of the SMN2 transcript. Spinraza causes the inclusion of exon 7 in the SMN2 transcript, leading to production of full length functional SMN protein. Spinraza can be appropriate for the treatment of spinal muscular atrophy in patients when there is confirmation of the diagnosis by either: SMA diagnostic test results confirming no copies of SMN1 or by molecular genetic testing of 5 q SMA for a homozygous gene deletion, homozygous conversion mutation, or compound heterozygote and when there is documentation of either genetic testing confirming no more than two copies of SMN2 or when there are SMA-associated symptoms before six months of age. In this case, the patient had significant symptoms beginning in adulthood with progressive symptoms beginning in his 40s. However, he has three copies of the SMN2 gene and is therefore not considered a candidate for treatment with Spinraza. Thus, the requested Spinraza is not supported as medically necessary for treatment of this patients spinal muscular atrophy. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing, BRCA1 and BRCA2 full sequence analysis.Findings:  Two of the three physician reviewers found that this patient was diagnosed with breast cancer. Additionally, the records document that her brother was diagnosed with pancreatic cancer. This patient meets criteria for genetic risk evaluation based on her personal history of breast cancer and family history of a first-degree relative with pancreatic cancer. Due to her increased risk, she is a candidate for BRCA1 and BRCA2 testing. This testing may have a significant impact on patient management. Studies found that preventive oophorectomy in patients with BRCA1 or BRCA2 mutations reduced ovarian, fallopian tube, and peritoneal cancers by 80% and all-cause mortality by 77%. The medical evidence supports the requested services in this patients case. In sum, the requested genetic testing, BRCA1 and BRCA2 full sequence analysis, is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in clinical genetics and genomics and are actively practicing. Physician reviewer 1 is board certified is clinical biochemical genetics and is 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