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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg tablets 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested 12 week course of Harvoni 90-400 mg tablets 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: Urgent Care
Decision: Upheld

The parent of a male enrollee requested psychiatric services for the enrollee on an emergent basis.  Findings:  The physician reviewer found that based on the documentation submitted for review, at the time of admission this patients screening was negative for suicide, self-harm or aggression. He was classified as a mild safety risk and was assigned to receive routine monitoring.  In sum, the patient was not an immediate danger to himself or others and was able to provide adequate self-care at the time of the services. Based on the documentation provided, the patient did not have a psychiatric emergency medical condition that required services provided on an emergent basis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested for continuous Euflexxa injections for treatment of her osteoarthritis.   Findings:  Three physician reviewers found that the submitted medical documentation does not detail how much conservative care (e.g., non-steroidal anti-inflammatory drugs dosage and duration, physical therapy type and duration, walking aids, home exercise program) has been tried and failed. All told, as evidenced by long-term, controlled and double-blind studies (see Benke and Shaffer, Chevalier and colleagues and Divine and colleagues) the medical literature to date has not demonstrated or validated the contention that viscosupplementation results in long-term efficacy from multiple re-treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the UroLift procedure for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested services.  The UroLift procedure is at best a temporary solution in this clinical setting.  There is a lack of peer-reviewed double-blinded studies which demonstrate that the UroLift procedure is more effective than transurethral resection of the prostate.  In sum, the requested UroLift procedure is not likely to be of greater benefit than other treatment options in this patients case. Final Result: Two reviewers determined that the requested services are 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 urology 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

A 51-year-old female enrollee requested anodyne light therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation failed to demonstrate the medical necessity of the requested services in this patients case. Per the current medical evidence, anodyne therapy fails to provide long-term benefits to patients with chronic pain.  Lavery and colleagues published a study to determine the effectiveness of anodyne monochromatic infrared photo energy (MIRE) in-home treatments over a 90-day period to improve peripheral sensation and self-reported quality of life in individuals with diabetes.  The authors concluded that anodyne MIRE therapy was no more effective than sham therapy in the treatment of sensory neuropathy in patients with diabetes.  Hsieh and colleagues published a study to investigate the effects of short-term light therapy with 890-nm radiation on physical activity, pain, and postural stability in patients with knee osteoarthritis.  The authors concluded that this treatment provided no beneficial effect in improving pain, physical activity and postural stability.  All told, the requested anodyne light therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested psychiatric treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that in light of the severity of the patients condition, outpatient therapy was not likely to be of significant benefit. The amount of comorbidity of this patients eating disorder, in combination with the confluence of his irritability and defiance, necessitated a higher level of care than outpatient therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous immunoglobulin therapy delivered in an inpatient hospital care setting for treatment of her common variable immune deficiency. The physician reviewer found that the medical records do not document that the patient had a significant reaction to the immunoglobulin therapy.  There is a lack of evidence of serious side effects during or following the treatment which would necessitate services in an inpatient hospital care setting.  The medical literature notes that serious side effects after intravenous immunoglobulin are very rare if infusions are given over an extended period in a well hydrated patient.  In this case, it may be appropriate to deliver her next infusion in an infusion center.  She could be pre-medicated and then receive the infusion over seven hours with careful observation of any side effects.  This could also be done in the providers office.  Assuming no documentation of side effects, subsequent infusions could be administered in her home.  All told, the requested intravenous immunoglobulin therapy delivered in an inpatient hospital care setting is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the ultrasound bone growth stimulator (CPT HCPCS-E0760 Osteogen Ultrasound Stimulator) for treatment of her medical condition.  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the device at issue.  According to the medical literature, further clinical trials are needed in order to determine the optimal role of ultrasound therapy and fracture healing.  The records did not include more recent clinical notes documenting the outcome of the start of physical therapy along with weight-bearing as tolerated.  Given that the patient was noted to have progression of healing with no documentation of updated repeat x-rays to show continued delayed union, the requested ultrasound bone growth stimulator was not and is not likely to be of greater benefit than available standard therapy.  Final Result:  Three reviewers determined that the device at issue was not and 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 orthopedic surgery 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

A 42-year-old female enrollee has requested Nuvigil (armodafinil) 150 mg for the treatment of her bipolar disorder. Findings:  The physician reviewer found that because of the number and variety of medication trials that have been prescribed in combination for this patient, as well as a pattern of rapid adjustment and discontinuation, there is inadequate clinical data to support a reliable assessment of this patients response to medication treatment. In addition, the combination of multiple mood stabilizers (including Lamictal, at a higher than customary dose), multiple antidepressants, and a stimulant in the absence of a planned treatment protocol is not likely to result in a successful outcome and is not medically indicated. Furthermore, the differentiation between iatrogenic induced somnolence secondary to medication side effects and the somnolence that is caused by the psychiatric condition itself is not obvious in this case. All told, there is insufficient clinical rationale for adding Nuvigil in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested Botox injections for treatment of her migraines.  Findings:  The physician reviewer found that in the peer reviewed medical literature, a randomized, placebo controlled, double-blind study (PREEMPT) was reported by Dodick and colleagues. The goal of the clinical trial was to evaluate the efficacy and safety of onabotulinumtoxinA (Botox) in the treatment of chronic migraine. Overall, the pooled results demonstrated that Botox is an effective prophylactic therapy for chronic migraine. The researchers concluded that Botox resulted in significant improvements compared with placebo in multiple headache symptom measures, and significantly reduced headache-related disability and improved functioning, vitality, and overall health-related quality of life. Moreover, the authors found that repeat treatments with Botox were safe and well tolerated. Based on review of this patients medical records, she has a headache history consistent with chronic migraine. In addition, the frequency equates to more headache days per month than days without headache. She therefore meets the U.S. Food and Drug Administration (FDA) criteria for diagnosis of chronic migraine. Moreover, she has been tried on several standard preventives as well as standard abortive treatment without success or with intolerable side effects. Given the scientific data establishing Botox as an effective treatment modality in patients with chronic migraine, this patient should receive treatment with Botox as it has been demonstrated to be medically necessary in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested hernia repair without mesh for treatment of his inguinal hernia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested procedure. Tissue repair of inguinal hernia has a higher recurrence rate than tension free or mesh repair. Open technique with mesh repair is considered the gold standard based on available published outcomes studies. Beitler and colleagues studied hernia repairs and concluded that, an accurate open preperitoneal approach using mesh prosthesis for complex inguinal hernias is safe, with very low recurrent rates and low morbidity. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested coverage for total hip arthroplasty for treatment of her hip pain. Findings:  Two physician reviewers found that the major advantages of resurfacing include preservation of the femoral head and neck permitting standard total hip replacement if required at a later date. In addition, the procedure allows for a larger head size, which increases stability resulting in fewer dislocations and providing greater mobility. Although additional studies are being conducted, experience with total hip arthroplasty has been encouraging to date. Furthermore, the patient is an appropriate candidate for the procedure given her young age.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee with a history of aplastic anemia.Findings:  Prior to transplantation, it is standard practice to check for telomere length for the diagnosis of dyskeratosis congenita (DKC). Knowing this information prior to transplantation is important because it can change the conditioning regimen required for bone marrow transplantation. In addition, individuals diagnosed with DKC are also at risk for other types of cancers and diseases. Thus, it would be an important assessment to make in terms of cancer screening and prevention. Currently, there is very limited available standard therapy. Testing for all conditions that can cause aplastic anemia is standard of care and it includes testing for telomere length.  Patients identified as having DKC may respond to a trial of androgen therapy and therefore, for treatment options it is imperative to know if DKC is present.  In addition, DKC can have long lasting medical problems, which would need continued monitoring and screening. For the reasons noted above, the gene panel testing was likely to have been of greater benefit than the available methods of evaluating this patient.Final Result: All 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 pediatrics with sub-specialty certification in pediatric hematology-oncology 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: The parent of an enrollee has requested pelvic floor physical therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that Pelvic floor physical therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Encopresis is a challenging condition to treat, especially in the pediatric population with behavioral issues. In addition, the identification of specific types of constipation is challenging in the pediatric population, as in this case, where a digital rectal exam was refused. In this clinical setting, empiric approaches for treatment become reasonable and appropriate. As such, pelvic floor training is both appropriate and likely to yield a positive outcome for treatment of the patients encopresis. Therefore, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested therapy 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: All three physician reviewers are board certified in pediatric 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an upright or standing magnetic resonance imaging (MRI) with contrast. Findings:  The physician reviewer found that as noted in the medical literature, CT imaging is the modality of choice for sinusitis due to excellent depiction of bone anatomy including anatomical variants. While MRI can also show presence and extent of sinusitis, it is not considered to be the first modality in the evaluation of sinusitis. This patient has a history of symptoms such as sinus pressure and frontal headache which suggests possible sinus problem, for which CT would be the appropriate imaging modality. Typically, intravenous contrast is not administered for evaluation of sinusitis. In addition, CT is faster than MRI and coughing would not pose a difficulty during the imaging. According to the American College of Radiology and Radiological Society of North America, the radiation dose in CT sinus is very minimal approximately 0.7 mSv as opposed to CT of the abdomen and pelvis with an effective radiation dose of 10 mSv, or PET/CT with an effective radiation dose of 25 mSv. Given the advantages of CT over MRI in evaluation of sinus, the requested upright or standing MRI with contrast is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ dispensed by a Board-Certified Pediatric Pharmacy Specialist. Based on the records provided for review, this patient presented for repeat visits with a height Z-score that is less than four standard deviations below the mean. Thus, he meets the current criteria for small for gestational age (SGA) with failed catch-up growth. However, there is a lack of data in the medical literature to support use of a pediatric pharmacist to determine the appropriate dose of recombinant growth hormone for this patient. The decision to start recombinant growth hormone and change the dose of growth hormone is made by a board certified pediatric endocrinologist based on the age, height and weight of the patient, growth over time and the results of laboratory testing including IGF-1 and IGFBP-3. All told, the requested Nutropin AQ dispensed by a Board-Certified Pediatric Pharmacy Specialist is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 pediatrics with subspecialty 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: Overturned

A 51-year-old female enrollee has requested Botox injections.  for treatment of her stated condition of migraines. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for patients with chronic headaches, there is adequate literature supporting its use in select patients.  In this patients case, she has failed multiple standard therapies for headaches and continues to experience headaches.  In this clinical setting, a trial of Botox injections is medically appropriate and is likely to be of greater benefit than other available treatment options.  Therefore, the requested Botox injections are likely to be more effective than other modalities for the treatment of this patients migraines.