Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for corneal collagen cross linking (procedure code 0402T). Findings:  The physician reviewer found that the patient is a 54-year-old male who presented to his provider with blurred vision and a history of laser assisted in situ keratomileusis. The patients provider noted a worsening astigmatism. The provider also noted that the patient requires rigid contact lens in the right eye.  Visual acuity measured 20/30 in the right eye and 20/15 in the left eye.  Per the provider, corneal topography showed inferior steepening of both corneas. The patients diagnosis was bilateral corneal ectasia. The provider recommended corneal collagen cross linking (procedure code 0402T). The Health Plan denied the requested procedure as investigational/experimental for the treatment of this patient. There is sufficient support in the medical literature for the superior efficacy of the requested procedure. The provider noted that this patients vision has continued to worsen. The vision loss is caused by the thinning corneas. The provider recommended corneal collagen cross linking procedure to prevent further degeneration.  Based on the patients vision loss and stage of ectasia, the crosslinking is the most appropriate and most effective treatment available. The body of evidence shows corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia. Moreover, this procedure has the potential in preventing the need for full-thickness corneal transplant. There are very limited treatment options for this eye condition. In sum, the requested corneal collagen cross linking (procedure code 0402T) is likely to be superior to any available treatment options for this patient. Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers are  board certified in ophthalmology 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 patient has requested authorization and coverage for (1) diclofenac epolamine 1.3% pain patches and (2) transforaminal epidural injection with imaging guidance (fluoroscopy or computed tomography), lumbar or sacral single level (CPT 64483).Findings:  The physician reviewer found that diclofenac epolamine topical patches may be effective for the treatment of acute soft tissue injuries, such as lumbar strains, sprains, and contusions, there is a lack of current medical literature to support their use for chronic low back pain and lumbar radiculopathy. In a systemic review and meta-analysis, Lee and colleagues concluded that lumbar epidural steroid injections were more effective than injections without steroids for improved pain relief and function. Manchikanti and colleagues reported that there is evidence supporting transforaminal epidural injections for the treatment of herniation or radiculitis. In this case, the patient has chronic low back pain with a history of L5-S1 fusion and presents with lumbar radiculopathy. She has tried and failed conservative care, including physical therapy. Given that the current medical literature does not support the use of diclofenac patches in this clinical setting, the requested medication is not medically indicated. As the patients provider has recommended epidural steroid injections to treat her left lumbar radiculopathy symptoms, the requested service is medically indicated. Therefore, (1) diclofenac epolamine 1.3% pain patches are not medically necessary for the treatment of this patient, while (2) a transforaminal epidural injection with imaging guidance (fluoroscopy or computed tomography), lumbar or sacral single level (CPT 64483) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service and medication are partially 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 anesthesiology with sub-specialty certification in pain 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: Overturned

A 43-year-old female enrollee has requested Celebrex for treatment of systemic lupus erythematosus.  Findings:  The physician reviewer found that Celebrex is the only available Cox-2 inhibitor or NSAID with a documented lack of antiplatelet effect, and as a result, is the agent of choice for patients taking Coumadin who need a non-steroidal anti-inflammatory agent for control of joint symptoms. Use of Celebrex in association with Coumadin may require adjustment of the Coumadin dose due to changes in protein binding, but this is not related to platelet inhibition. The use of Celebrex in this particular setting is medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for vein embolization CPT 37241 for varicocele. Current medical literature supports the use of percutaneous transcatheter scrotal varicocele embolization as a treatment option for men with symptomatic painful varicoceles. Sheehan and colleagues note that varicocele embolization results in a durable reduction in pain scores compared to their preoperative values. The authors further noted that among the measured quality of life parameters, varicocele embolization resulted in significant improvement in return to work, housework, socializing, exercise, sexual relations, and sleeping post-embolization. This treatment modality is associated with fewer surgical complications and high rates of durable treatment of the varicocele. In this case, the records note that the patient has large symptomatic varicocele with pain. While there are several treatment options available, the patients provider has recommended varicocele embolization due to the patients young age and the minimally invasive nature of this treatment. The decision to pursue this treatment is based on discussions between this patient and his physician regarding risks and benefits. Therefore, vein embolization CPT 37241 for varicocele is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested vein embolization CPT 37241 for varicocele is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 66-year-old male with prostatic symptoms. He reports to have had tried Cardura, Hytrin and to have had a laser prostatectomy yet remains symptomatic. He indicates he was given Avodart with improvement and wishes to obtain authorization and coverage for the medication. The Health Plan has denied the patients request on the basis that he must undergo a trial of alpha-blocker before being given an antiandrogen.The treatments for benign prostatic hypertrophy include: alpha-blockers such as Hytrin, Cardura and Uroxatral, antiandrogens such as Avodart and Proscar, and procedures such as transurethral resection of the prostate, laser prostatectomy, transurethral needle ablation (TUNA) or transurethral microwave therapy (TUMT).Avodart is a recognized and acceptable treatment for benign prostatic hypertrophy (BPH). It blocks the conversion of testosterone to dihydrotestosterone and results in shrinkage of the prostate. It takes a minimum of four to six months to see an effect.Alpha-blockers work immediately by relaxing the smooth muscle in the prostate.  Alpha-blockers are not medically equivalent to antiandrogens and are not a pharmacy substitution. Some patients improve with one type of medication and some with the other. In some cases patients are given both.The patient indicates he has already tried alpha-blockers without benefit. He has also had a laser prostatectomy so the tissue that Avodart works on, or that alpha-blockers affect, is typically gone. In theory, after a laser prostatectomy a transurethral resection is more likely to be effective in cases of BPH (90%) than either alpha-blockers or antiandrogens (50% to 60%). Nevertheless, it is appropriate that the patient be given an adequate trial of medication prior to further surgical intervention. Given the failure of alpha-blockers, the patients request for Avodart is medically reasonable and appropriate. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the OncotypeDX Prostate Assay. There currently are three major therapeutic strategies to the management of localized prostate cancer: surgical prostatectomy; various forms of radiation; or surveillance only with no specific cancer treatment. Clinical stage, PSA and biopsy pathology determine an individual patients risk category. Applying the current National Comprehensive Cancer Network (NCCN) guidelines, he falls in the favorable to unfavorable intermediate-risk category. This patient population provides a challenge in terms of treatment selection. The provider recommended testing to help determine whether he should have surveillance only, or undergo specific treatment. OncotypeDX Assay is a 17-gene assay of an individual patients cancer cells, with good predictive of recurrence after radical prostatectomy. For patients with localized prostate cancer, OncotypeDX can provide guidance for therapeutic decision-making. In this particular situation, OncotypeDX Prostate Assay 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 OncotypeDX Prostate Assay was likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Upheld

A 23-year-old male enrollee has requested Adderall for treatment of his attention deficit hyperactivity disorder.  Findings:  The physician reviewer found that based on review of the available records, this patients provider recommended Trazodone for insomnia and verapamil with Midrin for migraines. The patient indicated that he was only taking trazodone but declined other controlled medications including non-stimulants. Applying the recommendations from the American Society of Addiction Medicine (ASAM), the patient should first be given an adequate trial of medication as recommended by his provider. This is especially important as the patient has a prescription for cannabis and is therefore at a higher risk for abuse of stimulants. Thus, given this patients elevated risk he should first be given an adequate trial of medication pursuant to his providers recommendation. For these reasons, the medical necessity of the requested medication has not been established in this patients care at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A thirty-six year-old male with metastatic gastric cancer is requesting authorization for bevacizumab plus 5-FU.  Reviewers Findings:  The reviewing physicians found that bevacizumab still has unproven efficacy for this disease, and it is not possible to conclude that it is likely to be superior to standard chemotherapy in this setting.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials.  For these reasons, the requested treatment with Viekira Pak and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: The patient has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request and reported that the requested services are investigational for the treatment of the enrollees knee pain. A review of the records indicates the patient has a history of lumbar disc herniation, lumbar radiculopathy, fibromyalgia, rheumatoid arthritis, and left knee osteoarthritis. Previous treatments for her left knee pain have included cortisone injection and physical therapy. On 10/2/18, the records noted that the enrollee experienced pain relief from a previous Euflexxa injection, and she was able to decrease her use of anti-inflammatory drugs. The provider recommended repeating Euflexxa injections into the left knee. The Health Plan indicates that the requested services are investigational for the treatment of the enrollees medical condition. Therefore, the Health Plan has denied coverage for the Euflexxa injections. One reviewer found that the requested Euflexxa injections are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested Euflexxa injections are not likely to be more beneficial for evaluation 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 orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested authorization and coverage for growth hormone therapy with Nutropin for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that based on review of the available records, this patient does not meet standard criteria for GH deficiency, as his pre-treatment height is not more than 2.25 SDs below normal for age and gender, his pre-treatment growth velocity is normal, and growth factors are normal. His adult predicted height is not short enough to meet the Food and Drug Administration (FDA) criteria for a trial of GH therapy on the basis of idiopathic short stature. Although the patients adult predicted height is more than 2 SDs below the calculated mid-parental target height, note that his parents heights are on both extremes of the spectrum for adult height, and an accurate assessment of the genetic potential may be misleading using the formula for mid-parental height that averages the heights of the two parents. The most likely diagnosis is a combination of familial short stature and constitutional delay, for which GH treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records do not document that the patient has undergone diagnostic sleep testing in the form of polysomnography/multiple sleep latency test (MSLT) to confirm a diagnosis of narcolepsy. Current diagnostic standards for narcolepsy require objective findings on a MSLT to establish a diagnosis of narcolepsy. Furthermore, while it is also noted that modafinil is a non-formulary drug, the Health Plan does have other central nervous system stimulant agents which have otherwise been shown to be effective for the treatment of daytime sleepiness due to narcolepsy. There is not sufficient clinical information regarding the patients cardiovascular history to determine that the use of these other wake promoting agents on the formulary would otherwise be contraindicated for use in this patient. The current medical evidence does not support the requested medication in this clinical setting. Therefore, modafinil 100 is not medically necessary for the 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 neurology with sub-specialty certification in sleep 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

A 45-year-old female enrollee has requested for a referral to a sports medicine certified orthopedic physician for treatment of her right hip pain.  Findings:  The physician reviewer found that it is uncertain whether the patient has a labral tear which could be confirmed by MRI arthrogram.  Assuming confirmation of a diagnosis of labral tear, a surgical approach consisting of labral debridement with or without the use of suturing technique and bone anchors would be an appropriate intervention for that diagnosis. . The appropriate surgical care for labral lesions is not a separate discipline in orthopedic surgery, but rather an application of basic arthroscopic surgical techniques to the labrum of the hip joint. A significant reference supporting this decision is that teaching both the diagnostic criteria and the appropriate treatment techniques is an integral part of orthopedic surgical training.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested intensive outpatient therapy for treatment of the enrollees bulimia nervosa, purging type, and depressive disorder. Findings:  The physician reviewer found that the submitted documentation does not demonstrate medical necessity for intensive outpatient level of care from the date of service at issue onward. The patient was 123.8% of her ideal body weight. At that time, the patient denied physical symptoms or compensatory behaviors. In addition, the submitted logs indicate the patient was meeting her meal plan regularly. Further, a psychiatric evaluation demonstrates the patient did not meet criteria for major depressive disorder. Her global assessment of functioning (GAF) score was 55 indicating moderate symptoms. At a later date, progress notes describe the patient as relatively stable. She again denied physical symptoms or compensatory behaviors, and food logs indicated improved compliance. Based on American Psychiatric Association (APA) and Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines for the treatment of patients with eating disorders, the patient no longer met criteria for intensive outpatient therapy as of the date of service at issue. As of that date, the medically necessary level of care for this patient was outpatient therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100mg-40mg, three times daily, for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret 100mg-40mg, three times daily, for eight weeks. Zeuzem and colleagues reported that the ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100mg-40mg, three times daily, for eight weeks is medically necessary for 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 a 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.