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

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute hospitalization services for treatment of the enrollees pulmonary embolism, status post tracheostomy, asthma, atrial fibrillation, chronic kidney disease, and possible cerebrovascular accident (CVA).  Findings: The physician reviewer found that based on the records provided the patient has a history of multiple comorbid medical conditions. She presented with congestive heart failure requiring intravenous diuretics. Though the patients left ventricular ejection fraction (LVEF) was reported to be only mildly reduced, there is a poor correlation between ejection fraction and severity of heart failure since diastolic dysfunction, atrial fibrillation, valvular heart disease and other factors can be contributory. Moreover, given her documented frequent emergency department visits, aggressive diuresis is indicated to help reduce the risk of recurrent congestive heart failure and hospital readmission. Given the need for intravenous diuresis and the patients several comorbid conditions, the requested acute hospitalization services are appropriate and considered standard accepted practice in the medical community. The patient management in this case cannot be safely or effectively provided at a lower level of care. For these reasons, the requested acute hospitalization services are medically necessary for treatment of this patients medical condition.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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested a referral to a dermatologist for the treatment of her steroid-induced ecchymoses/skin fragility. Findings:  The physician reviewer found that this patient complains of moles, painful liver spots and has a family history of skin cancer.  On physical examination, the primary care physician does not note any lesions that are suspicious for skin cancer.  The physician indicates that the patient suffers from steroid-induced atrophy and vascular fragility with easy bruisability. These diagnoses do not require treatment by a dermatologist, as there is no effective treatment for these conditions. The physician did not identify any suspicious moles of which the patient complains. The patient did not indicate specific lesions of concern at the time of the exam according to the medical records. Based upon the submitted documentation, the patient does not present with signs and symptoms for which referral to a dermatologist is medically warranted.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the Afirma Gene Expression Classifier (GEC) for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewers found in this case, the patients initial biopsy demonstrated FLUS. Thus, additional testing with Afirma GEC was indicated to help determine the need for surgery. Afirma testing is generally considered standard protocol on all FNA samples for thyroid nodules. Moreover, there is sufficient peer-reviewed medical literature to support the utility of the Afirma GEC in this clinical setting. For these reasons, the Afirma GEC provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that 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 overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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:  An enrollee has requested the takedown of Rouxen-Y gastric bypass and conversion to a duodenal switch for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records do not document any overt complication of the prior open gastric bypass.  It is unclear that this patient would be compliant with a revisional type procedure to offset the increased risk of complications of revisional surgery.  All told, the requested takedown of Roux-en-Y gastric bypass and conversion to a duodenal switch 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the manipulation under anesthesia of the shoulder for treatment of the enrollee who has a history of shoulder pain. Findings:  The physician reviewer found that There is support in the medical literature for the efficacy of the services at issue in this patients case. The patient has a healed fracture of the clavicle. He was also found to have adhesive capsulitis of the shoulder with limited range of motion. At the time of hardware removal, the provider checked the range of motion of the shoulder, found the presence of adhesive capsulitis, and performed manipulation under anesthesia to improve the range of motion of the shoulder. Manipulation under anesthesia is commonly performed for treatment of adhesive capsulitis and in this patients case was appropriate. The medical literature with regards to the manipulation under anesthesia for adhesive capsulitis support the efficacy of this technique in this clinical setting. As such, manipulation under anesthesia of the shoulder was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Shingrix, 50mcg/0.5ml. The enrollee has a rash to her back. The progress note reports the symptoms occur randomly. The enrollee has a history of recurrent shingles. The progress note indicates the enrollee will accept topical therapy, but that systemic therapy has resulted in a 30 percent hair loss. She returned to her provider due to another outbreak, which began one week prior. The provider ordered Valtrex, 1000 milligrams per day, and ordered a shingles vaccine for the enrollee. The physicians diagnosis at that visit was herpes zoster with complications. She reports having experienced 13 episodes of shingles since over the last year and a half. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support this service as likely to be more beneficial than any other standard treatment. A thorough search of the literature did not yield any robust studies for which shingles vaccine was effective in this age group and diagnosis. Shingrix is not approved for those younger than age 50.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in allergy and immunology 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: Overturned

A 53-year-old male enrollee has requested Enbrel 50mg, twice per week for treatment of his psoriasis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication dosage in this patients case.  The medical records document chronic plaque psoriasis, and the patient is HIV positive.  On prior occasions, he has reduced the dosage of Enbrel to 50mg weekly, and he experienced flare ups of his psoriasis.  The current medical evidence indicates that some patients require higher doses of Enbrel for better control of psoriasis.  In this patients case, the documentation indicates lack of control of his psoriasis at lower dosages.  All told, Enbrel 50mg, twice per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an esophageal manometry with impedance for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients symptoms, as well as her evaluation that preceded the disputed services, were inconsistent with significant gastroesophageal reflux or esophageal dysmotility.  The current medical evidence does not support the services at issue in this clinical setting.  Indications for esophageal manometry include diagnosis of suspected primary and secondary motility disorders, as preoperative assessment for patients undergoing anti-reflux procedures, and to reassess esophageal functions in patients who have been treated for a primary esophageal disorder or who have undergone anti-reflux surgery.  The disputed testing may be indicated for patients with symptoms of heartburn or nausea after eating or problems swallowing.  In this patients case, the records do not demonstrate the indications for the disputed testing.  All told, esophageal manometry with impedance was not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Overturned

A 56-year-old male enrollee has requested intravitreal injections of Avastin for treatment of the enrollee, who has been diagnosed with severe central serous retinopathy. Findings:  Three physician reviewers found that this patient has a history of central serous retinopathy causing vision loss and scarring in the macula. The use of Avastin was based on progression of the disease and the suspicion of choroidal neovascularization.  It is well-established that Avastin is safe and effective for a number of diseases that are characterized by choroidal neovascularization.  The medical literature supports the use of Avastin in the treatment of other types of retinal diseases involving neovascularization. In this patients case, the physician recommended intravitreal Avastin injections primarily based on the suspicion of choroidal neovascularization. Alternative treatments, such as photodynamic or observation, would likely not be as beneficial for this patient.  Therefore, intravitreal injections of Avastin were and are likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Supartz injection for the left knee. Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has moderate to severe left knee pain due to osteoarthritis following a history of remote arthroscopic meniscectomy. The patient has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Supartz injection for the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.Findings:  Three physician reviewers found the medical evidence supports a portion of the services at issue in this clinical setting. Per the American College of Obstetricians and Gynecologists, screening for thrombophilias is not recommended for a history of pregnancy loss. However, since the patient reported that she is of Ashkenazi Jewish descent, screening for Tay-Sachs should be offered. There is support for Tay-Sachs screening during pregnancy if either member of the couple is of Ashkenazi Jewish descent. Therefore, Tay-Sachs screening was likely to have been more efficacious than other available methods of evaluating this patient. However, the superior effectiveness of MTHFR testing has not been established. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.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 authorization and coverage for Epclusa 400 mg-100 mg tablets. Findings:  The physician reviewer found that the physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. Delay in treatment may result in decreased survival. Therefore, Epclusa 400 mg-100 mg tablets are 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 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 parent of a 10-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy in a school setting. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.   The request for ABA therapy in a school setting is not medically necessary for the treatment of the patients medical condition. There is a lack of documentation provided to support the requested ABA services in a school setting. The documentation submitted for review does not include clinical documentation from the school that describes information regarding the patients behavior at school. There is a comment that his non-compliance and aggression are worse at school, but no further details are available. Although continued ABA therapy and parent training are clinically indicated for the patient, in addition to speech and occupational therapy, there is a lack of documentation provided to support ABA therapy as medically necessary in a school setting.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 and neurology with special qualification in child neurology 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 63-year-old hypertensive male with a history of cough possibly related to use of benazepril (Lotensin). His hypertension is controlled on a combination of Toprol XL and Norvasc. The Health Plan indicates the patient does not meet criteria for authorization of Norvasc. Therefore, the Health Plan has determined Norvasc is not medically necessary.The patient has a documented history of intolerance to benazepril due to cough. The patients blood pressure is in control on a combination of a beta and calcium channel blocker, Norvasc. There is no documentation of a trial of other calcium channel blockers such as Plendil or Sular. These medications are likely to be equally effective as Norvasc. As such, there is insufficient evidence demonstrating Norvasc is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three 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 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 53-year-old female enrollee has requested  for intravenous Rocephin for treatment of her Lyme disease. Findings:  Three physician reviewers found that treatment of Lyme disease with long-term antibiotics is a controversial area as is evidenced by the included literature. Currently, there are two sets of guidelines (IDSA and IILADS). For the patient presented, there is no objective evidence of persistent infection with Borrelia (Lyme) or other infectious agent. Numerous long courses of antibiotics have been used without success. Further treatment with intravenous Rocephin for greater than 30 days would be considered experimental or investigational in nature, since no large scale, controlled trials have concluded that the proposed treatment is effective.