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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center level of care services provided. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In terms of her anorexia, the patients body mass index entered the range of normalcy by the slimmest of margins. However, she still had orthostatic changes and lightheadedness.  Further, she had continued urges to restrict and purge, along with co-occurring mood symptoms and anxiety. The patient remained in a precarious state and had not consolidated the treatment gains necessary to maintain a healthy weight in a less restrictive setting. Psychiatrically, diphenhydramine was added upon admission to address insomnia, while the bupropion was reduced. The patients nystagmus was thought to be due to the bupropion dose reduction, so the taper was temporarily suspended. The diphenhydramine was replaced with eszopiclone as the patient feared going to sleep, and the prazosin was increased.  Thus, the patients medication regimen was in the midst of significant reconfiguration. Symptomatically, the patient was depressed with anhedonia, hopelessness, anxiety and suicidal ideation. She was psychiatrically unstable. In sum, the services and setting were and are safe, appropriate and consistent with good practice. Additionally, the services provided were and are reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming.  All told, residential treatment center level of care services provided were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the requested therapy is medically necessary and is considered the standard of care for the treatment of patients with HCV genotype 1. Harvoni is expected to be beneficial for this patient by potentially curing his HCV infection and preventing further damage to his liver. It is also noted that treatment with anti-viral drugs such as Harvoni halts the progression of the disease process and development of cirrhosis, long-term and its potential complications including liver failure, liver cancer and death. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of sustained virologic control (SVR). Therefore, as per the American Association for the Study of Liver Diseases (AASLD) guidelines, the patient should be approved for Harvoni for 12 weeks to prevent further development and progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term. Delaying treatment could result in further progression of fibrosis, development of cirrhosis, future risk of hepatic decompensation or hepatocellular carcinoma. For these reasons, the requested course of Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan (CPT 78815). Findings:  The physician reviewer found that (NCCN) guidelines, evaluation with a PET scan can be considered after a computed tomography (CT) scan in high-risk patients to detect extra-pancreatic metastases. Indicators of high-risk patients includes borderline resectable disease, markedly elevated CA 19-9, large primary tumors, or large regional lymph nodes. Wang and colleagues noted that, PET can be used as a valuable diagnostic and predictive tool for pancreatic cancer, but its effect in the staging of pancreatic cancer remains indeterminate. In this case, the patient has a history of pancreatic cancer, and she may be considered for resection if no metastatic disease is found on PET. In this clinical setting, the recommended PET scan is appropriate for initial staging. For these reasons, the requested PET scan (CPT 78815) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 57-year-old male enrollee has requested participation in the STOP-AF clinical trial of the Arctic Front Cardiac Cryoablation Catheter System for the treatment of his atrial fibrillation. Findings:  Two physician reviewers found that the patient is markedly symptomatic and would benefit from an ablation for symptom relief.  Medical therapy has failed to aid his overall symptoms secondary to paroxysmal atrial fibrillation. Electrophysiologic study combined with ablation for cardiac arrhythmias seems to have significant advantages over antiarrhythmic drug therapy and may improve outcome. Guidelines suggest considering the use of catheter ablation for failure to respond to antiarrhythmic drug therapy or when medical therapy is contraindicated because of comorbidity or intolerance.  The use of cryothermal ablation, rather than radiofrequency ablation, may decrease the risk of permanent heart block.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tecfidera 240 mg twice daily. Tecfidera (dimethyl fumarate) is indicated for the treatment of patients with relapsing forms of multiple sclerosis (MS) at a starting dose of 120 mg twice daily for one week, followed by maintenance dosage of 240 mg twice daily. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with MS include respecting and evaluating patient preferences to improve acceptance of and adherence to DMT. Patient preferences may include the safety, route of administration, lifestyle, efficacy, common adverse effects, and tolerability in the choice of DMT. Dimethyl fumarate (BG-12) (Tecfidera) as an oral treatment has been shown to significantly reduce relapse rates, the development of new brain lesions on MRI, and rates of disability progression in patients with active MS. Scientists found that patients experienced improved effectiveness of treatment with dimethyl fumarate over first-line agents such as interferons, glatiramer acetate, and teriflunomide, and similar effectiveness to treatment with fingolimod. Researchers concluded that fingolimod had more safety issues than the other two agents. For this reason, it should be strictly monitored for risks of infections, cancers, and certain transitory effects such as irregular cardiac function, decreased lymphocyte count, and a higher level of liver enzymes. The authors noted, The main risks marked with dimethyl fumarate were flushing and gastrointestinal events. In this case, the patient has a diagnosis of relapsing remitting MS. The provider presented and weighed options for DMT and determined Tecfidera as most effective, considering the route of administration, efficacy and safety for the patient, and the patients preference to avoid injectables. Based on the current medical literature, Tecfidera has an efficacy superior to or comparable with the other approved DMTs such as Extavia, Glatopa, and Gilenya, and its safety profile is potentially less harmful than Gilenya, the other oral alternative. Therefore, Tecfidera 240 mg twice daily is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 60-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that the patient has a history consistent with disabling migraine. She is not a good candidate for triptans due to CAD, and opiates have been of limited benefit, implying a need for preventative treatment. The frequency of attacks appears to be high, as a wide variety of preventatives have been employed. Success has been limited due to side effects or lack of adequate improvement. There is considerable data demonstrating Botox has a positive benefit as a migraine preventative, especially when the frequency of attacks is high (chronic migraine). There are no FDA approved treatments for chronic migraine, and the standard medications used as migraine preventatives have already been tried in this case, with the exception of Depakote. Individuals who try and fail three migraine preventatives are often considered refractory, and do not tend to respond well to oral preventatives. However, refractory migraine may still respond to Botox.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for a 12-weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to 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 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. A delay in treatment may result in decreased survival. 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 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: Overturned

A male enrollee requested Harvoni 90/400 mg for 12 weeks for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Moreover, per AASLD/IDSA, HIV/HCV-coinfected patients suffer from more liver-related morbidity and mortality, nonhepatic organ dysfunction, and overall mortality than HCV-monoinfected patients. Based on the reasons provided above, Harvoni is medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested photodynamic therapy and Visudyne for the treatment of his central serous retinopathy. Findings:  The physician reviewer found that  the standard of care in the treatment of CSR is still observation. Studies have shown that the final visual outcome is essentially the same whether the retina is treated with laser or just observed. There is evidence that the eye treated with laser has a better chance of recovering more quickly than observation, but unless there is a significant reason the patient requires a faster recovery (i.e., bilateral involvement with poor vision in the better eye), observation is still considered the standard of care. Recent studies have suggested that low dose PDT with Visudyne can result in safely reducing the subretinal fluid in patients with CSR more quickly than observation. That said, there has not been a large, prospective, randomized study showing that the final visual outcomes are better in patients treated with low dose PDT with Visudyne compared to those who received no treatment. If patients present with poor vision in both eyes, PDT is medically appropriate, however, this patients vision was 20/20 to 20/25 in the left eye. In sum, low dose PDT with Visudyne is not the standard of care, nor has it been shown in large prospective studies to be better than the standard of care of observation in patients with CSR.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old male with symptoms suggesting sleep apnea, with no evidence of special risk factors (such as obesity, hypertension, cardiac disease) and mild daytime sleepiness with an Epworth score of 9. Sleep study documents mild sleep apnea with an apnea-hypopnea index of 11.9/hr, no significant oxygen desaturation, and no documented apnea.Review of the relevant medical literature reveals no benefit of CPAP in mild cases of sleep apnea when compared to placebo. An apnea-hypopnea index of 11.9 is compatible with mild apnea and does not meet criteria for treatment. A threshold of 15 or 20 is usually invoked unless there are additional risk factors. This patient has no documented additional risk factors. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for mastectomy (CPT code 19303) with nipple areola reconstruction (CPT code 19350). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients back pain. The submitted documentation does not support the medical necessity of the requested services. This patient has well-documented evidence of significant, symptomatic macromastia. This patient has evidence of chronic back and neck pain as well as photographs indicating shoulder grooving. This has significantly impacted the patients daily activities. The medical documentation submitted for review, including a review of the photograph, supports that the patients macromastia is likely contributing significantly to the functional complaint of pain. However, this patients clinical presentation supports the need for a possible breast reduction, not a mastectomy. Therefore, the requested mastectomy (CPT code 19303) with nipple areola reconstruction (CPT code 19350) is not medically necessary 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 plastic 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has reportedly benefitted from viscosupplementation with Orthovisc injections of both knees every six months for six years. Thus, the patient is a good candidate for additional viscosupplementation of both knees with Orthovisc. Therefore, the requested Orthovisc injections in both knees are medically necessary for treatment of 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 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: Overturned

A forty year-old female with multiple sclerosis is requesting coverage of a TriLite ultra light manual wheelchair.Reviewers Findings:  The reviewing physician found that the patient is unable to adequately maneuver the power-operated wheelchair through the doors and around the furniture in the home; the patient requires a manual wheelchair for mobility within the patients home.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested mastopexy and augmentation mammoplasty for the treatment of her breast deflation due to Graves disease.   Findings:  The physician reviewer found that the augmentation mammoplasty and mastopexy are not medically necessary for this patient. The condition does not constitute an abnormal structure of the body. There is no loss of functioning documented in the records. There is no abnormal structure or abnormally functioning structure of the body due to congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The patients breast atrophy is likely a combination of factors including weight loss and aging, as well as some effect from Graves disease. However, the patients breasts are not structured abnormally or deformed. Nor is there a functional impairment that would be improved by the proposed procedures.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex interlaminar stabilization device (CPT 22867). Based on the documentation provided for review, this patient meets the criteria for surgical intervention. He has medically refractory lumbar radiculopathy due to a large lumbar disc herniation. The records document failure of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and injection therapy. His providers initial plan to recommend a microdiscectomy at the affected level is the standard of care surgical approach for the treatment of lumbar radiculopathy caused by a disc extrusion. In addition, the records suggest that the patients symptoms have meaningfully improved from 9/10 to 2/10 on the pain scale. Considering this improvement, a repeat magnetic resonance imaging (MRI) is needed to determine if the disc herniation is still present and requires surgical intervention. Moreover, there is a paucity of data in the peer-reviewed medical literature comparing lumbar microdiscectomy to microdiscectomy plus Coflex for the treatment of lumbar radiculopathy from a lumbar disc herniation. Two non-randomized studies compared lumbar microdiscectomy to microdiscectomy plus Coflex and reported incongruent findings. One study suggested improved outcomes after seven to nine months of follow-up with decompression plus Coflex while the second study countered these findings. Overall, there are insufficient data supporting the utilization of the Coflex device in conjunction with lumbar decompression versus lumbar decompression alone for lumbar stenosis with or without stable grade 1 spondylolisthesis. In sum, the requested Coflex interlaminar stabilization device (CPT 22867) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Coflex interlaminar stabilization device (CPT 22867) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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: Physician reviewers 1, 2, and 3 are board certified in neurological 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.