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

A 31-year-old male enrollee has requested Menopur injections for the treatment of his hypogonadotrophic hypogonadism or Kallmanns syndrome. Findings:  The physician reviewer found that both testosterone and sperm are deficient in men with hypogonadotrophic hypogonadism. Some men require both LH and FSH replacement with an hMG such as Menopur to achieve full reproductive function. Thus, Menopur is being utilized in this case for purposes of sperm production to treat the patients infertility. There is no clinical indication for Menopur for treatment of the patients underlying conditions of hypogonadotrophic hypogonadism or Kallmanns syndrome.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female who was referred to a neurologist because of many intermittent symptoms including incontinence (urinary and fecal), myoclonus, paresthesias, fatigue and shortness of breath. Pertinent lab results included a normal chest x-ray and an elevated serum ACE level. The neurologist indicated the patients symptoms were typical for multiple sclerosis, but there was also clinical concern of sarcoidosis as a cause of her symptoms. A spiral CT of the chest was performed in October 2004 for which the patient is seeking reimbursement. At issue is whether the spiral CT was medically necessary for evaluation of the patients medical condition.A spiral CT of the chest was ordered to determine if the patient had sarcoidosis, which can affect both the central nervous system and the pulmonary system. An elevated serum ACE can indicate that the patient has sarcoidosis. In order to appropriately treat this patient, it was important to determine if the patient had sarcoidosis with or without the diagnosis of multiple sclerosis. Chest x-rays are not always sensitive in the evaluation of hilar and/or mediastinal adenopathy. CT (spiral) of the chest is the diagnostic exam of choice to evaluate for hilar and mediastinal adenopathy. The NIA criteria allow authorization of a chest CT for known or suspected inflammatory disease including sarcoidosis. In conclusion, the spiral CT of the chest performed in October 2004 was medically appropriate and necessary for the diagnosis and treatment of this patients condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene test (Foundation One) for evaluation of the enrollees colon cancer.  Findings: Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines for colon cancer, testing for mutation in the KRAS, NRAS and BRAF genes are advised for metastatic disease to determine efficacy of EGFR inhibitors such as Vectibix and Erbitux. However, all other mutations are not necessary to determine treatment. In this clinical setting, the testing for KRAS, BRAF and NRAS was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested radiofrequency ablation of the nerves (CPT Code 64622 and 64623) for treatment of her chronic right lower back and sacroiliac joint dysfunction. Findings:  Two physician reviewers found that there is a paucity of quality peer reviewed medical literature on sacroiliac joint denervation. The available studies are small and with many limitations, including the selection of the correct patients for the procedure. Further, the current American Pain Society practice guidelines, as discussed by Chou and colleagues, do not consider sacroiliac joint denervation a viable treatment option. For these reasons, it remains investigational. Moreover, there is no specific documentation on whether this patient received physical therapy or bracing for her sacroiliitis or regarding how the patient responds to pain medication. All told, there is insufficient evidence to support that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested bio-identical hormone pellet therapy with re-dosing every 3 to 4 months for treatment of her status post hysterectomy.  Findings:  Three physician reviewers found that there is no evidence that compounded bio-identical hormones are safer or more efficacious than standard FDA-approved and tested options. In fact, because of issues related to compounding, dosing is frequently inconsistent.  This may actually increase the risk of such treatments. While the patients provider indicates that the patients recent hysterectomy was the trigger of her menopausal symptoms, she is in her mid-60s and it is likely that she became menopausal before her surgery. There are numerous FDA-approved hormone therapies available for menopausal symptoms, with oral and non-oral route options. Available FDA-approved therapies include bioequivalent estradiol, molecularly identical to human hormones that do not require compounding, and the dosage and pharmacokinetics are well established. There is no evidence from the records provided that these alternate treatments have been tried and failed. At the present time, compounded bio-identical hormone replacement therapy is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy, and may in fact pose additional risks.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee has requested inpatient psychiatric services for treatment of his depression.  Findings:  The physician reviewer found that the patient presented with significant medical problems which compounded the issue of which conditions in fact contributed to his altered mental state. Furthermore, he had a reported head injury prior to the admission. The patient was not consistently alert and was not described as cognitively clear until the date in question. Consistent with the American Psychiatric Association (APA) practice guidelines for the treatment of patients with bipolar disorder, this patients condition clearly merited the level of care provided during the period at issue. His medical condition was not stabilized consistently until his discharge date. Thus, the inpatient psychiatric services provided from the dates in question were medically indicated and necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female with a history of L5-S1 laminectomy in 1984 and spinal disease apparently related to a traumatic injury in 2004. She has been treated with non-steroidal anti-inflammatory drugs and Flexeril and has achieved some symptomatic relief. MRI indicates severe disc collapse at L5-S1 and disc bulge at L4-5. The patients provider recommends fusion from L4 to S1 and revisional foraminotomies using a 360 degree approach. The providers request for authorization was denied by the Health Plan citing a lack of medical necessity.A thorough review of the MRI reports and clinical notes provides no clear indication for surgical intervention at L4-5. There is a central disc bulge but no evidence of foraminal encroachment. The basis for the dynamic component of foraminal compression alluded to cannot be ascertained from the records provided. The patient clearly has disc degeneration, Modic changes of the endplates and foraminal compression at L5-S1 and her symptoms appears related to disease at that level. I can find no medical rationale for the proposed L4-S1 anterior-posterior fusion. Additionally, I find no reason why the pathology at L5-S1 cannot be addressed from a posterior approach through either a PLIF or TLIF procedure. There is no compelling evidence in the medical literature that would favor a 360 approach through two separate incisions over a single posterior technique. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas). Laparoscopic myomectomy is an option for the treatment of symptomatic fibroids recommended by the American College of Obstetricians and Gynecologists (ACOG). Researchers report that laparoscopy has supplanted laparotomy. While the U.S. Food and Drug Administration (FDA) discourages the use of uterine morcellation due to oncological risk, the authors note that this is controversial, and that the recommendation has been challenged by a part of the profession. The use of power morcellation has been used for some time to aid in the removal of the fibroids, and with the addition of precautions and patient education, continues to be an accepted and recommended course of treatment that has been well-studied and with well-known risks and benefits for symptomatic uterine fibroids. Therefore, power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) 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 power morcellation of uterine fibroids (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) is 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 service 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 reviewer 1 and 3 are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested a sleeve gastrectomy (43775) for treatment of her obesity. Findings:  Three physician reviewers found that the current medical literature has confirmed the validity of the sleeve gastrectomy as an acceptable stand alone procedure.  Additionally, the laparoscopic sleeve gastrectomy is the easiest to revise, if necessary. Disadvantages of the gastric bypass surgery that are not found with the sleeve gastrectomy include nutritional deficiencies, unpredictable absorption in the distal small bowel, dumping and possible marginal ulcer formation if NSAIDs or steroids become necessary.  In this patients case, the requested sleeve gastrectomy is likely to be superior over all other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100mg/40mg tablets. The submitted documentation supports the medical necessity of the requested medication. 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 cirrhotic treatment-naive genotype 1a patients should be treated with Mavyret 100/40 mg three tablets daily for 12 weeks. These recommendations are based on multiple randomized clinical trials, including the EXPEDITION-1 trial showing a 99% cure rate, 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. Although a viral load is not provided in this case, the feasibility of genotype and resistance testing proves that there is circulating and detectable Hepatitis C virus. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested medication is medically necessary for this patient.Final Result: The reviewer determined that the requested services 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 a subspecialty certificate 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:  An enrollee has requested Subsys for treatment of her chronic pain syndrome.  The physician reviewer found that according to the current peer-reviewed medical literature, fentanyl sublingual spray (Subsys) is a novel formulation of fentanyl for sublingual delivery and was designed to enhance the rate in extended absorption of fentanyl for management of breakthrough cancer pain. According to the clinical records submitted for review, the patient utilizes this medication due to a history of side effects with previous medications, and difficulty swallowing and digesting oral medications and is in constant, severe pain. However, the clinical records submitted for review provide no evidence or indication that the patient is currently experiencing breakthrough cancer pain or that the patient has been diagnosed with any form of cancer. Further, the clinical records submitted for review lack exceptional factors which would warrant the use of this medication. Based on the documentation submitted and in consideration of the diagnosis, the care provided, and the clinical condition, as well as the medical history of the patient, the requested Subsys medication is not medically necessary. 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 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: Upheld

The patient is a 46-year-old male with a history of substance abuse and depression. In June 2005 the patient was admitted to a partial hospitalization program. A patient assessment completed on admission indicated that his mother and father were supportive; that he had a marked weight loss; that he was binging on cocaine on a daily basis (up to $200-300/day); that he was isolating himself; that he was motivated for treatment; that he was sad, irritable and angry, and that he was just getting settled into a Sober Living house with several other men. The submitted chart notes reflect the following. A psychiatric evaluation performed in June 2005 noted a prior history of major depressive disorder characterized by depressed mood, anhedonia, insomnia, suicidal ideation and hopelessness even when sober. Current symptoms included some hopelessness, isolation and worthlessness (at times), but no suicidal ideation. A mental status evaluation was positive for a depressed mood, but revealed normal psychomotor function, orientation and memory. No dangerousness or suicidal or homicidal ideation was noted. A history of job changes was noted. A diagnosis of depression - not otherwise specified was given along with cocaine dependence and a possible cocaine-induced mood disorder. At issue is whether the partial hospitalization services were medically necessary.A detailed review of the submitted treatment records does not demonstrate the services at issue were medically necessary. There is an absence of any evidence of any suicidal or homicidal ideation or activity prior to or at the time of admission or at any time during the treatment. In addition, the patient had supportive parents and also his own motivation for services. The patient had a supportive living environment that specifically was designed as a Sober Living home. The patients illness did not manifest a level of severity of illness that met nationally recognized guidelines for partial hospitalization. It is recognized that this patient has a co-occurring disorder, which is a very frequent finding among individuals presenting for treatment of depression. While he initially presented with concerns over his cocaine abuse, the inter-relationship with his depression is significant and the approach to both issues concurrently is consistent with current best practices. However, such treatment could have been provided at a less intensive level of care. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. 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 emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient sustained fractures of the left distal radius and ulnar styloid. The medical records submitted for review do not support that the services provided were emergent given the patients fracture complexity. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Praluent pen 75 mg/mL (alirocumab). The U.S. Food and Drug Administration (FDA) approves the use of Praluent (generic name alirocumab), a proprotein convertase subtilisin-kexin type 9 (PCSK9), for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of low-density lipoprotein cholesterol (LDL-C). Robinson and colleagues note that PCSK9 inhibitors have been shown to reduce LDL-C levels in patients who are receiving statin therapy. Cannon and colleagues note that in patients with acute coronary symptoms, when added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. In this case, while the patient has some coronary risk, the documentation does not support a diagnosis of heterozygous familial hypercholesterolemia with elevated LDL-C levels that significantly exceed 180 mg/dL, or a or a strong family history of coronary disease. Physical examination did not document findings such as arcus cornealis below the age of 45, or tendon xanthomatas. The records do not reflect angina, ischemic electrocardiogram change, or ischemia on stress testing. The documents do not reflect trials of specific statin medications, such as pitavastatin and Fluvastatin, which may have lower side effect profiles. While the provider noted that the patient was not sufficiently controlled on ezetimibe, the documentation does not reflect that the patient was unable to tolerate this medication, which has been shown to improve outcome in patients with a variety of responses. Given that the current medical literature does not support the of PCSK9 inhibitors in this primary prevention setting, the requested medication is not medically indicated. Therefore, a Praluent pen 75 mg/mL (alirocumab) 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 internal medicine with sub-specialty certification in cardiovascular 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.