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

The patient is requesting a consultation with an ocuplastic surgeon to assess the degree of visual dysfunction from her drooping eyelids and/or eyebrows. She states she needs to raise her eyebrows in order to see through the drooping eyelids. It appears a taped visual field exam was performed, as was a separate visual field exam on a different date. The submitted photographs are fair to poor quality. It is difficult to tell if the patient is contracting the frontalis muscle to elevate the eyebrows from the quality of the photographs. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary for evaluation of the patients condition.Based upon the information provided, surgical authorization is not medically necessary at this time; however, it is medically reasonable for the patient to receive a consultation with an ocuplastic surgeon to take appropriately lighted/focused/oriented photographs, and to examine the position of the eyelids and eyebrows with the patients upper facial musculature in repose. It would also be helpful to obtain serial visual fields with the patient in a relaxed mode and as well as with her eyelids/brows manually elevated/taped to determine the degree of visual field improvement. Performing the two fields on the same date would eliminate confounding factors in the test results. As such, I have determined that the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 7-week-old male enrollee has requested Synagis therapy for Respiratory Syncytial Virus (RSV) prevention. Findings:  The physician reviewer found that although this patient does not meet all of the criteria as set forth in the AAP guidelines, he is at risk for significant morbidity and even mortality from RSV disease by virtue of his gestational age, gender, and birth weight, as demonstrated by the above studies.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested neuromuscular electrical stimulator (NMES) home unit for treatment of his decreased left upper extremity status post brain abscess.  Findings:  The physician reviewer found that the records provided for review do not document what specific gains were accomplished with the NMES unit. The provider noted the patient made slight gains but does not document how this was measured or determined. It was also noted that the patient made gains with physical therapy and his home program. The records indicate he has continued with 3+/5 strength throughout the left upper extremity without changes reported with the NMES. All told, no distinction can be made between the patients progress made with physical therapy with and without NMES. Therefore, the requested device is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Euflexxa injections for the right knee. The enrollee has ongoing pain of the right knee. She has experienced benefit with hyaluronic acid (Euflexxa) injections in the past, but only temporary relief, lasting one week, with cortisone injections.  The enrollee reports she received Euflexxa injections previously and the effects lasted for a year.  The physician requested authorization for the injections again. Literature describes osteoarthritis as a common condition; resulting in pain, reduced mobility, and decreased function. Studies have shown corticosteroids short-term pain improvement and can be used for flares. Recent studies have shown hyaluronic acid (Euflexxa) injection demonstrates longer-term improvement in both pain and function. A professional society recommends intra-articular hyaluronic acid (Euflexxa) injection for the treatment of knee osteoarthritis for adults who do not respond to other treatment options. Literature supports hyaluronic acid injection for cases of osteoarthritis in situations where the individual declines surgical intervention.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1a.  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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). Given this support, the requested Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Alprazolam (Xanax). A review of the records indicates the patient with a history of grief, anxiety and depression came for renewal of her anxiety medication. Findings: The physician reviewer found that  the enrollee has been on Alprazolam for a long time and takes Norco for pain, as well. She had tried a number of medications that did not work as well as Alprazolam for her anxiety and/or caused side effects. The enrollee had panic attacks and was not able to leave the house or work. Alprazolam worked best to help her with these issues and she does not want to try other medication. The treatment plan was to taper Alprazolam and start a trial of gabapentin. According to the medical literature, Alprazolam has the potential to be addictive. Due to its addictive potential and sedating effects when given with Norco, it would not be considered safe to prescribe these two medications at the same time. The medical literature indicates the use of opioids and benzodiazepines should be avoided while taking Alprazolam. There are other first line medications for the treatment of panic disorder, which are not considered benzodiazepines.  Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Nutropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients idiopathic short stature. The submitted documentation supports the medical necessity of the requested medication. The patients height is more than standard deviations below the mean the patients for age and gender, insulin-like growth factors -1 level is low, growth velocity is poor, and adult predicted height is less than 63 inches. Although the patient had normal results on provocative GH testing, the patient meets generally accepted criteria established by the Pediatric Endocrinology Society and the U.S. Food and Drug Administration for treatment of idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature; who pass GH stimulation tests, but who meet several of the following criteria; height is more than 2.25 standard deviations below the mean for age, or more than two standard deviations below the mid-parental height percentile; or growth velocity of less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factors-1 and/or insulin-like growth factor-binding protein 3; and/or other clinical features suggestive of GH deficiency. This patient does meet several of the above criteria. Therefore, Nutropin is medically necessary 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 a Senza High Frequency spinal cord stimulator for treatment of his medical condition. Findings:  Three physician reviewers found that there is a lack of support for the requested device in this clinical setting.  High frequency spinal cord stimulation is a new approach to providing analgesia in failed back surgery syndrome.  This modality is currently undergoing a clinical trial in various chronic pain states.  Although some research presents promising data, the studies to date are small and have been funded by the company.  In sum, the current medical evidence has not established the superior efficacy of the requested device. Final Result: Three reviewers determined that the requested 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.  Credentials/Qualifications:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood). Findings:  The physician reviewer found that Fetal aneuploidy testing including trisomy 13, 18, and 21, is consistent with the current guidelines from the American College of Obstetricians and Gynecologists (ACOG). However, the ACOG and Society of Maternal Fetal Medicine caution that testing for microdeletions have not been clinically validated. Furthermore, expanded carrier screening panels do not replace previous risk-based screening recommendations. The availability of expanded carrier screening does not preclude the appropriateness of ethnic based screening or screening based on family history. For these reasons, the fetal aneuploidy testing for trisomy 13, 18, and 21 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the fetal aneuploidy testing for trisomy 13, 18, and 21 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the fetal aneuploidy testing for trisomy 21, 18, and 13 portion of the gene test (fetal sex and fetal chromosome microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in the maternal blood) was 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 obstetrics and gynecology 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: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  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, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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

This 32-year-old female enrollee has requested an MRI of the lumbar spine for an evaluation of her lower lumbar pain. Findings:  The physician reviewer found that this patient does not meet the established guidelines for MR imaging of the lumbar spine. A physical examination revealed negative straight leg raises, normal strength bilaterally, normal deep tendon reflexes bilaterally and normal gait. The patient did report a dullness in sedation on the left lateral leg. At this juncture, there are no significant neurological deficits and x-rays show only scoliosis. The patient has not yet had a complete trial of physical therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 30 Veltassa 8.4 g packets a month.Most individuals with hyperkalemia have chronic kidney disease or are treated with a medication that inhibits the renin-angiotensin-aldosterone system (RAAS). Mild-to-moderate hyperkalemia (5.5-6.5mEq/L) should be treated with dietary modification, diuretics, and treatment of chronic acidosis. If this is not effective, then the medications that inhibit the RAAS should be reduced or discontinued. If this treatment is not effective, then potassium binders can be utilized. Patiromer (Veltassa) can be used in hyperkalemic emergencies when the potassium must be lowered quickly, as it can be effective within an hour. In this case, there is no indication that loop diuretics have been contraindicated in this patient in an outpatient setting. There is no indication that any steps have been taken to prevent the hyperkalemia without a potassium binder medication. Thus, the requested 30 Veltassa 8.4 g packets a month are not medically necessary for the treatment of the patients medical condition.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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for positron emission tomography (PET) scan (with concurrent acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh) provided 9/14/20.National Comprehensive Cancer Network suggests that patients should consider multiphasic abdominal/pelvic computed tomography/magnetic resonance imaging (CT/MRI) with intravenous (IV) contrast and chest CT with contrast every three to six months for two years, then every six to twelve months for up to five years, or as clinically indicated. In this case, the patient was diagnosed with cholangiocarcinoma in 2014. The recommended 5-year follow-up period had been completed. Based on the records, there were no clinical signs that he had a recurrence. No other clinical indications for repeat imaging outside the usual 5-year follow-up period were identified. As such, PET scan (with concurrent acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh) provided on 9/14/20 was not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for three months for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that since this patient is genotype 1b, as per the data from the clinical trials and American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Viekira Pak should be used alone and the addition of ribavirin is not recommended. The Health Plan has approved Viekira Pak with ribavirin. Viekira Pak and Harvoni are both considered first-line therapies with similar patient outcomes in terms of sustained virologic response. However, this patients provider has recommended Harvoni to avoid use of ribavirin. For these reasons, the requested Harvoni is medically necessary for treatment of this patients hepatitis C virus genotype 1b infection. Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are 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 a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the U.S. Food and Drug Administration (FDA), more data is required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, medical literatures reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remain to be determined. Researchers report that severe dysphagia requiring endoscopic intervention was more frequent with LINX than with surgical fundoplication. Researchers found that erosion of the LINX device is an important but rare complication to recognize. The authors noted that LINX has significant potential adverse effects and may be associated with poorer outcomes. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested LINX procedure 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 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. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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.