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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tazverik 200 mg tablets. This patient presents with a history of clival chordoma that has progressed despite treatment with resection and re-resection, proton beam radiation therapy, afatinib, and nivolumab plus relatlimab. The patients provider has recommended treatment with Tazverik. The U.S. Food and Drug Administration (FDA) has not approved Tazverik for the treatment of clival chordoma, which is a bone sarcoma. Tazverik has been approved by the FDA for epithelioid sarcoma, which is a type of soft tissue sarcoma. The National Comprehensive Cancer Network (NCCN) and major drug compendia do not recommend treatment of bone sarcoma with Tazverik. Currently, the utility of Tazverik in chordoma is limited to pediatric phase I data. On review of the medical literature, there is a lack of clinical studies demonstrating that Tazverik is safe and effective for the treatment of clival chordoma. Therefore, the requested Tazverik 200 mg tablets are 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 internal medicine with subspecialty certifications in medical oncology and hematology 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

The patient is a 51-year-old woman with an extensive history of orthopedic and spinal surgery. Her treating physician variously labels her underlying condition as rheumatoid arthritis, psoriatic arthritis, degenerative joint disease, seronegative spondyloarthropathy, B27-positive rheumatoid arthritis, and fibromyalgia. The patient has been treated with an array of agents including DMARDs, prednisone in fairly high doses, three biologic agents, methotrexate, leflunomide, cyclophosphamide, narcotic pain medications, anti-anxiety agents, and antidepressants. The submitted information indicates that at one point the patient was simultaneously taking methotrexate, leflunomide, Enbrel, and Kineret, but still required prednisone between 20 and 60mg daily for benefit. The records only detail subjective changes with all of the regimens described. A request has been made for intravenous Rituxan therapy. The Health Plan has denied the request indicating that a diagnosis of rheumatoid arthritis or any type of inflammatory arthritis has not been established.The requested therapy is not medically indicated. There is no objective clinical evidence or laboratory data presented in the providers frequent office notes from June 2002 to September 2003 to clarify the patients diagnosis. No clinical evidence has been presented to support a diagnosis of rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy or any inflammatory joint disorder. Furthermore, the patients reported lack of response to extensive and aggressive treatment raises the possibility that no inflammatory illness is present. Indeed, there are patients with severe and recalcitrant inflammatory joint disease who do not respond well to current therapies, leading to continuing interest in b-cell inhibition, and other mechanisms, such as IL-6 antagonism. However, the submitted clinical records provide no objective evidence that such is the case with this patient. Rather, the record is suggestive of a somatoform pain disorder with underlying degenerative disc disease. Such conditions would be expected to show no response to aggressive treatment aimed at an inflammatory joint disorder.Therefore, in the absence of a clear diagnosis of any inflammatory disease, or even undefined joint inflammation, treatment with Rituxan is not medically indicated. As such, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for the Regeneten Patch. This patient presents with complaints of grade 5/10 right shoulder pain with a history of prior rotator cuff repair 20 years ago. The patient has documented functional limitations and clinical examination findings are consistent with imaging evidence of a partial-thickness infraspinatus tear. The records include detailed evidence of trial and failure of a recent, reasonable and comprehensive non-operative treatment protocol. Her treatment plan includes rotator cuff repair with the Regeneten Patch. Overall, there is a paucity of large volume, long-term peer-reviewed outcome studies to support the use of the Regeneten Patch for revision rotator cuff repair. Schlegel and colleagues evaluated 33 patients and reported that arthroscopic implantation of a bioinductive collagen scaffold is a safe and effective treatment for intermediate- to high-grade partial-thickness rotator cuff tears of the supraspinatus tendon. Bokor and colleagues found that their study on 13 patients demonstrated the ability of a highly porous collagen implant to induce new tendon-like tissue formation and create an environment conductive to the healing of partial-thickness cuff tear. The physician reviewer found that the current data supporting the clinical utility of the Regeneten Patch include small patient sample sizes without randomization. A clinical trial is underway to demonstrate arthroscopic surgical treatment of high-grade partial-thickness tears using Regeneten yields statistically superior patient postoperative recovery outcomes, faster return to activities of daily living, and less health care utilization versus standard surgical repair techniques. These data will help determine whether the Regeneten Patch has a role in revision rotator cuff repair. All told, the requested Regeneten Patch 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 Regeneten Patch 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 medical device is 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.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services deem an emergency. Findings:  The physician reviewer found that For a hospital to hospital transport, air ambulance is indicated if using a ground ambulance would endanger the patients health and if the initial hospital cannot provide necessary medical services. Certain specialized services are not available at all hospitals. This patient was in an inpatient hospital. She was hemodynamically stable with mild hyperphosphatemia, but otherwise normal laboratory values. There is no documentation to support that the patient suffered an acute change in her condition warranting emergency air ambulance transport. Rather, the records indicate that this was a planned transport for inpatient eating disorder services following an acute hospitalization. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency 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: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with a history of arthritis, congestive heart failure, renal failure, diabetes, and peripheral neuropathy. She is seeking authorization for a power-operated vehicle (POV). The Health Plan indicates the patient does not meet authorization criteria for a POV and has denied authorization for the requested equipment. Information from March 2006 indicates the patients gait was unstable with a walker but could probably improve with physical therapy. Information from April 2006 indicates the patient could functionally ambulate in the home with a front-wheeled walker. It was also indicated a POV would not fit in the patients home. Therefore, a manual wheelchair was recommended. Based upon this information, the patient does not meet accepted criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested thyroid surgery for treatment of her thyroid nodule.   Findings:  The physician reviewer found that the patient maintains that she has difficulty breathing and swallowing due to the nodule, however there is no objective documentation of this complaint and no evidence of this complaint until after surgery was requested.  There is no evidence that the nodule has enlarged to account for the new symptoms and the patient was not symptomatic when the nodule was initially discovered.  Finally, the patient has not been compliant with medical therapy for her hypothyroidism, which may in fact result in an overall decrease in the size of the thyroid gland and improve her described symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of his hepatitis C virus.Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested therapy in this patients case.  This patient meets criteria for growth hormone treatment as the records document he was born small for gestational age with failure to catch up in growth by two years of age.  According to the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children with intrauterine growth restriction/small for gestational age is an indication for growth hormone treatment.  Provocative growth hormone testing is not required for diagnosis and treatment for this indication.  Small for gestational age or intrauterine growth restriction cause a pathophysiologic process in utero that adversely affects fetal growth.  Treatment with growth hormone in children with intrauterine growth restriction may stimulate substantial catch up growth during the first two years of treatment, followed by a slower but constant increase in growth.  All told, the requested Genotropin growth hormone therapy is 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 residential treatment center level of care services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records noted mild post-acute withdrawals.  She was not a danger to herself or others, and she was not showing self-injurious behavior. She was medically and psychiatrically stable. Lexapro and trazodone could have continued to be monitored on an outpatient basis.  There were no emotional, behavioral, or cognitive issues that would have prevented her from receiving continued treatment at an ambulatory level of care.  She was motivated and aware of triggers, actions to take, and the impact her behaviors had on her family, relationships, and employment situations. She was an active participant in treatment and demonstrated insight and the development of coping skills.  Although she did remain at risk, she indicated that she knew what she must do to prevent relapse. The records indicate that the patient could have continued her treatment at a lower level of care during the dates of service at issue. She no longer required the restrictive setting of residential treatment, and could have been released to the ambulatory setting, in conjunction with a 12-step program, substance abuse counseling, and a sponsor. All told, residential treatment center level of care services were not medically necessary for the treatment of this patient. 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

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 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al).  Per the records, the patient is ineligible for the alternative treatment for genotype 1a, Viekira Pak with ribavirin, due to a pre-existing medical condition. Studies show that this pre-existing medical condition can be exacerbated by ribavirin. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene expression analysis and protein biomarker, with CPT code 81479. As noted by researchers, there is interest in analysis of certain biomarkers as novel tools to improve prostate cancer risk assessments. The authors reported that although several of these novel biomarkers have an improved predictive accuracy that is better than classical parameters, there is still a need for further well-designed, large, multicenter, prospective trials to avoid common bias and clinical validation. Similarly, other researchers concluded that with the development of genetic expression panels careful study and validation of these tests and integration into clinical practice will be critical to realizing the potential of these tools. Given the lack of data supporting equivalent or superior patient health outcomes with use of genetic testing in this circumstance, the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the gene expression analysis and protein biomarker, with CPT code 81479, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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 42-year-old female with a body mass index (BMI) of 44. Based on the submitted information, it appears the patient has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. The patient has requested authorization and coverage for gastric bypass surgery. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.With a BMI of 44 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested for a wireless capsule endoscopy for evaluation of his renal cell carcinoma.   Findings:  Three physician reviewers found that there is inadequate evidence-based data proving the utility of wireless capsule endoscopy in the diagnosis of chronic abdominal pain. The requesting provider has not indicated a specific rationale for the diagnostic procedure. Further, there is nothing in the medical record supplied for review to indicate that GI bleeding of small intestinal origin is suspected as a cause of the patients GI symptoms. Moreover, there is no evidence that the patient has been evaluated radiographically, either with small bowel radiography or with CT enterography. These modalities have been demonstrated to be superior to wireless capsule endoscopy in the evaluation of abdominal pain of small bowel origin.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested magnetic resonance imaging (MRI) of the knee for medical evaluation of his knee pain. Findings:  The physician reviewer found that an x-ray of the left knee revealed minimal degenerative changes and physical exam showed mild effusion, but no evidence of joint looseness. Lower extremity MRI is indicated for persistent knee pain unresponsive to 4-6 weeks of conservative treatment followed by a clinical re-evaluation. In this case, the medical records do not document that a trial of conservative treatment such as anti-inflammatory medication and physical therapy has been tried and failed. Based on the clinical documentation submitted for review, the medical necessity for the MRI of knee has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of leg vein (heat treatment). for treatment of her bilateral leg pain. Two physician reviewers found that there is clinical support for the efficacy of the requested services in this clinical setting.  Moreover, there is sufficient documentation with respect to the severity of this patients symptoms and her failure of conservative efforts to relieve these symptoms.  The patient had a reasonably recent assessment of lower extremity arterial perfusion. There is documentation of leg edema as well as varicose veins.  There is documentation of reflux at the saphenofemoral junction with a significantly enlarged accessory saphenous vein. The treating provider had assessed that correction of that reflux would be a benefit to the patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in vascular surgery 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.