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

 Nature of Statutory Criteria/Case Summary: An enrollee has requested osteochondral allograft transplantation (transplant cartilage cells to his patella bone) for treatment of his medical condition.  Findings:  Three physician reviewers found that evidence-based medical guidelines and peer-reviewed literature support the use of osteochondral allograft transplantation as a primary or salvage procedure for large chondral or osteochondral defects.  Generally, the literature has supported the use of osteochondral allograft in the weight-bearing portions of the medial or lateral femoral condyle.  However, current long-term evidence exists for the use of osteochondral allograft in the patella. There is peer-reviewed evidence to support the use of cartilage repair as a primary procedure versus microfracture.  Given the age of this patient, functional loss, failure of conservative treatment, and the imaging findings of a large osteochondral lesion, the requested services are likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested services are 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: Medical Necessity
Decision: Overturned

A 30-year-old male enrollee has requested authorization and coverage for Celebrex 200 mg twice per day for treatment of the enrollees arthritis.  Findings:  The physician reviewer found that based on review of the available records, this patient is at very high risk for GI bleeds and complications associated with NSAIDs. He has severe pain in his ankles and deformity of motion in his elbow. The patient has tried other more potent Cox-2 inhibitors in the past and is not able to take non-selective Cox inhibitors. The guidelines for Celebrex state a dose of 200 mg per day for 6 weeks as initial treatment of osteoarthritis, and if not responsive, dosages of up to 400 mg in the form of 200 mg twice daily is reasonable. This patient has taken Celebrex for more than 6 weeks and has found that the 200 mg dose is not effective enough for analgesia due to chronic inflammatory pain from arthritis. Due to his normal kidney, cardiovascular and GI function, and co-morbid hemophilia, he is an excellent candidate for Celebrex (Cox-2) therapy for inflammatory pain due to multi-joint arthritis. At this point, he should be approved for up to, but not exceeding, Celebrex 200 mg twice daily (#60) capsules per month as needed to allow continued analgesia and limit the risks of bleeding associated with the hematological side effects of NSAIDs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic surgical ablation of uterine fibroids. The records document that this patient has a history of heavy menses and uterine fibroids. Per the imaging reports, the patient was determined to have at least six round uterine masses consistent with fibroids. The patients provider has recommended treatment with laparoscopic surgical ablation of uterine fibroids. As noted in the medical literature, the current surgical options for uterine preservation in the treatment of patients with uterine fibroids include hysteroscopic and/or abdominal myomectomy, uterine artery embolization, magnetic resonance imaging (MRI) guided focused ultrasound surgery, and radiofrequency ablation. Per the American College of Obstetricians and Gynecologists (ACOG) recommendations, Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation. Chudnoff and colleagues found that ablation was associated with a significant reduction in leiomyoma symptoms with no device-related adverse events and a low surgical reintervention rate through 12 months. The authors concluded that radiofrequency ablation of uterine fibroids is well tolerated with good symptom relief and improved quality of life. All told, the requested laparoscopic surgical ablation of uterine fibroids is 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 obstetrics and gynecology 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 digital breast tomosynthesis for evaluation of the enrollee who presented for a breast screening mammogram.  Findings: Two physician reviewers found that the patient was evaluated with screening mammogram and digital breast tomosynthesis. The report noted stable findings with no evidence of malignancy. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is evidence-based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective to this patient than had her examination been performed using two dimensional imaging alone.Final Result: Two reviewers determined that the service 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 21-year-old female with chronic pain who is requesting Actiq for pain control as several other pain medications have not been effective. The patient has been taking Actiq since 2002 and indicates it is the only medication that has provided her with relief. The Health Plan has denied coverage for Actiq on the basis that it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Actiq is not indicated in this patients condition and it is generally utilized for cancer pain refractory or tolerant to long-term opioids. No documentation has been provided demonstrating medical necessity for the use of Actiq. The patients chronic pain condition is related to cervical facet syndrome. Though the patient has a significant chronic pain syndrome, there are other established medications for non-cancer related breakthrough pain. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 73-year-old male enrollee has requested a brain PET scan for evaluation of his memory loss. Findings:  The physician reviewer found that the relevant scientific evidence includes a few small studies that favorably compared the accuracy of PET to clinical evaluation for differentiating fronto-temporal dementia from Alzheimer's disease. In view of the limited therapeutic options, however, the clinical value of this technique is unproven. Per the American Academy of Neurology guidelines: `PET scanning appears to have promise for use as an adjunct to clinical diagnosis, but further prospective studies with PET are needed to establish the value that it brings over and above a competent clinical diagnosis.` Given the lack of compelling evidence of added clinical benefit in this setting, the medical necessity of PET scan for evaluation of memory loss and/or possible Lewy Body dementia is not established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female who has been diagnosed with osteoarthritis of the left knee. On 5/24/12, the patient underwent a left knee partial medial meniscectomy. On 4/19/13, the patient underwent a third Orthovisc injection to the left knee. She reported 50% to 60% improvement with prior Orthovisc injections. On 6/26/19, the patient reported left knee pain with swelling, stiffness, and medial tenderness. Physical examination findings included tenderness over the left knee medial and lateral joint lines. The patient has requested authorization and coverage for Orthovisc injections to the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections to the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, her options are limited, with the alternative being a total knee arthroplasty. The physician reviewer found that medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections to the left knee are medically necessary for the 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy (including CPT codes 77014, 77263, 77336, 77427, 77470, 77523, and G6002). In this this clinical setting, there is medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for this patients orbital tumor. The patient requires a high radiation dose to the orbit of at least 60 Gy, which is above the tolerance of the nearby optic structures. The proton plan is able to effectively spare the orbit, optic nerve, and optic chiasm compared to what a standard photon plan would achieve. Furthermore, this technique may allow for preservation of the eye so that the patient will not require orbital exenteration. Based on these reasons, the proton beam radiation therapy (including CPT codes 77014, 77263, 77336, 77427, 77470, 77523, and G6002) was and is likely to be more beneficial for treatment of the patients medical condition than standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline 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.  This patient should be considered ineligible for Viekira/ribavirin due to her medical history, which can be exacerbated by ribavirin. For these reasons, the requested treatment with Harvoni is 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

A 22-year-old male female enrollee requested services on an emergent or urgent basis. Findings:  The physician reviewer found that criteria for urgently needed services were not met in this case. The patient presented to the facility while four months pregnant but had no other significant medical condition.  She denied suicidal/homicidal ideation, intent, or plan; there was no evidence of self-harming behaviors. She did not have any functional limitations in her daily activities or personal care. The patient was not in acute withdrawals nor was she intoxicated and the care provided could have been rendered in a less acute setting on a non-urgent basis. In sum, the criteria for urgently needed services were not met in this case. There was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of the health of the patient or her fetus. Thus, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA 1 and 2 Comprehensive Duplicate/Deletion and BART testing. Findings:  Two of three physician reviewers found that there is a lack of support for the requested services in this clinical setting. There are multiple guidelines as to who should be tested for cancer susceptibility genes, with most of the focus being on BRCA. In this patients case, neither the personal history of melanoma nor the family history support BRCA testing. In sum, BRCA 1 and 2 Comprehensive Duplicate/Deletion and BART testing are not likely to be of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for Xeljanz. The Health Plan has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The current guidelines continue to recommend a second necrosis factor inhibitor over Xeljanz (tofacitinib). In this case, the patient has a history of seropositive rheumatoid arthritis and fibromyalgia. At this time, the records fail to demonstrate that she has a contraindication to a second necrosis factor inhibitor trial. As such, Xeljanz is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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.Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has major depressive disorder.  In a letter the provider noted that the patients depression has not responded to pharmacotherapy or psychotherapy. The patients prior medications have included venlafaxine, paroxetine, nafazodone, escitalopram, bupropion, nortriptyline, and mirtazapine, and augmentation has been attempted with lamotrigine, olanzapine, quetiapine, aripiprazole and ziprasidone. The patient has requested coverage for transcranial magnetic stimulation.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patients treatment-resistant major depressive disorder is well-documented.  Her previous treatment has included mood stabilizers and augmentation strategies, including second-generation antipsychotics.  She had a prior psychiatric hospitalization.  There is support in the peer-reviewed literature regarding the efficacy and safety of transcranial magnetic stimulation in this clinical situation.  George and colleagues confirmed the benefit and safety of transcranial magnetic stimulation for adult patients with major depression.  In 2008, Janicak and colleagues noted that transcranial magnetic stimulation has demonstrated efficacy in the treatment of major depressive disorder.  Demitrack and Thase noted that transcranial magnetic stimulation is safer and better tolerated than many other pharmacotherapeutic options or electroconvulsive therapy.  All told, the requested transcranial magnetic stimulation is likely to be superior over other treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee, who has been followed for diabetic foot care, has requested authorization for Anodyne therapy. Findings:  Two physician reviewers found that Anodyne therapy is an unproven mode of physical therapy that lacks validation. The efficacy of Anodyne therapy has not been established through significant, case-controlled studies. There is no evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the LINX procedure. Based on the current peer-reviewed medical literature, the LINX device should be an option available to patients for the management of medically refractory gastroesophageal reflux disease (GERD). However, in this patients case, the available records do not support an indication for LINX implantation in lieu of maximized medical therapy and improved lifestyle and diet aimed at GERD management. The provider noted that the patient has GERD based on pH testing. The records support an absence of advanced esophagitis and normal lower esophageal sphincter (LES) function that does not require augmentation. In addition, the patient has reportedly achieved substantial benefit from acid suppression treatment. As such, she is not considered refractory to medical therapy nor is her acid suppression treatment ineffective or poorly tolerated. Moreover, the available records support at least intermittent dysphagia in the absence of dysmotility, warranting clinical caution before embarking on LINX implantation. Given these findings, the LINX procedure was not 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 LINX procedure was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in 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.