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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gelsyn-3 injection series in the left knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 received viscosupplementation every six months for the past three years and has had good benefit. Furthermore, the patients alternative is a unicompartmental knee arthroplasty. Therefore, the requested Gelsyn-3 injection series in the left knee is medically necessary for treatment of the patients medical condition.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: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with stage III primary peritoneal cancer who most likely received first line paclitaxel and carboplatin prior to 2003.  She has also received the following treatments: Doxil, gemcitabine, carboplatin, cisplatin and Navelbine. There is no record that she has received topotecan or etoposide. There is no mention of palpable tumor or CT results in the record. The patient was not able to tolerate high-dose paclitaxel due to peripheral neuropathy, and her physician initiated treatment with Abraxane. Apparently the status of her disease is being monitored by CA-125 levels (alone), and her CA-125 level has decreased since treatment with Abraxane began. The Health Plan has denied authorization for Abraxane on the basis that it is not medically necessary.Considering the patients history of neuropathy and her heavy platin use, Abraxane is a reasonable, clinically appropriate choice of drug that appears to be effective for her. The NCI-GOG study included for review related to patients clinically without evidence of disease after first-line therapy and is not strictly applicable to this patient. The Nyman study however is relevant; it includes three subjects with partial response to Abraxane and supports the position that Abraxane is clinically appropriate for this patient. If the patients CA-125 levels become elevated it would be appropriate to stop the Abraxane as the patients provider has done with the other agents that were not helpful.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that genotype 1b patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 94% cure rate. While both Zepatier and Viekira are recommended as first-line therapy, neither is reported to be superior by the guidelines. Overall, no head-to-head comparison has shown the superiority of Viekira over Zepatier in this patient population. 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 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

A 58-year-old female enrollee has requested reimbursement and out of network surveillance studies (laboratory and imaging) per the Phase II Clinical Trial of Interferon Alpha-based Adjuvant Chemoradiotherapy for her pancreatic cancer.  Findings:  The physician reviewer found that it is unlikely that she had an adequate EUS evaluation of the specific area along the lateral border of the SMA. As such, it is possible that there are both regional and distant recurrences and the reading by the Health Plan was not incorrect. The Health Plan indicates a willingness to perform ongoing surveillance studies in-Plan and to communicate these results to the trial site at the out of network medical center.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for platelet-rich plasma injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the nature of Statutory Criteria/Case Summary: There is limited reliable clinical evidence to guide the use of platelet-rich plasma injections. Although no major long-term or permanent complications have been reported in relatively short-term clinical trials, it remains to be seen what the results will be with more widespread application of platelet-rich plasma injections in the knee. Long-term benefits of platelet-rich plasma injections have not been demonstrated yet in the knee. Short-term benefits, lasting from six months to over a year, include functional improvement and pain relief. Such effects have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. The effects of platelet-rich plasma on knee osteoarthritis are quite mixed, and the research is not high quality. The majority of published data suggests better symptomatic relief with early osteoarthritis.  In this patients case, there are no reports of standing knee radiographs grading the degree of osteoarthritis or magnetic resonance imaging (MRI) reports showing how much articular degeneration is present.  This patient is 59 years old, and the cited studies demonstrate decreased efficacy in individuals age 50 or older.  In addition, the overall body of supporting literature is of poor quality and fails to demonstrate improved outcomes with platelet-rich plasma injections compared to standard available therapies for the treatment of knee osteoarthritis.  Therefore, platelet-rich plasma injections were not likely to have been superior over other available treatment options. Final Result: Two of three reviewers determined that the services at issue were 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continuous glucose monitor (CGM) and equipment for treatment of his type 2 diabetes (insulin dependent).   Findings:  The physician reviewer found that the American Association of Clinical Endocrinologist guidelines recommend CGM in type 1 and type 2 diabetes patients. The guidelines state, `Meaningful monitoring in patients with [Type 2 Diabetes Mellitus] T2DM should also be individualized depending on the risk of hypoglycemia estimated based on prior history, presence of hypoglycemia unawareness, and the nature of the current therapy (e.g., whether the patient is receiving medications with relatively high hypoglycemia risk, such as insulin, sulfonylureas, or glinides).  The guidelines further state, In T2DM as in T1DM, CGM can be useful in patients with unappreciated hyperglycemia, as well as in patients who are at high risk for hypoglycemia, those who have hypoglycemia unawareness, and those using intensive insulin therapy. Although this patient has a diagnosis of type 2 diabetes, his symptoms need to be managed in the same way that a patient with type 1 diabetes should be managed. As such, the patient should have access to the same tools as a patient with type 1 diabetes (i.e., CGM). The records demonstrate the patient is compliant with therapy and wants to be under better control with CGM.  In sum, CGM is a diabetes self-management tool that is more appropriate than standard management with fingerstick 4 times a day in this specific patient with diabetes type 2. Monitoring with CGM will allow the patient to make adjustments to therapy with avoidance of hypoglycemia. As such, the requested CGM and equipment is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment 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 endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A thirty-four year-old female with metastatic breast cancer is requesting authorization for Sutent therapy.Reviewers Findings:The reviewing physician found that Sutent is still an experimental treatment for metastatic breast cancer and cannot be considered medically appropriate at this time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a magnetic resonance imaging (MRI) of the lumbar spine for medical evaluation of her lumbar radiculopathy.   Findings:  The physician reviewer found that the written notes by the referring provider do not include a thorough neurological exam to support an indication for the requested MRI of the lumbar spine. Plain films of the lumbar spine were reportedly performed, but the results are not in the chart for review. In addition, there has been no documented attempt at conservative management including physical therapy. Absent any red flags, there is no documented medical necessity for MRI of the lumbar spine absent a course of conservative management.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who has undergone gastric bypass surgery with a resultant weight loss of 150 pounds. She reports problems with skin rashes and odor, primarily in the area of her large pannus. There is no indication in the record she has been treated for skin conditions or functional limitations in the areas of her hips, thighs or buttocks. An abdominoplasty was reportedly authorized by the Health Plan and it was performed in October 2006. The patient is currently requesting authorization for excision of excess skin and subcutaneous tissue from her hips, thighs and buttocks. The Health Plan denied her request citing a lack of medical necessity.The records do not establish medical necessity for the requested surgery for the patients hips, thighs and buttocks. There is no documentation in the form of primary care or dermatology progress notes that describes ongoing clinically significant dermatologic problems or functional impairment in these areas. Surgical lipectomy should be reserved for patients that have failed optimal medical management which is not the case in this instance. The abdominoplasty that was performed in October 2006 will likely rid the patient of much of her excess skin, eliminate chronic rashes under the pannus and simplify her hygiene. The patient was not sick from the excess skin in the areas of her hips, thighs, and buttocks and this condition does not appear to jeopardize her health.  The requested procedures are desirable for aesthetic reasons, but they are not medically indicated.Based upon the information set forth above, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a transgender male enrollee has requested authorization and coverage for bilateral breast mastectomy. Findings:  The physician reviewer found that the documentation provided supports the requested procedure in this clinical setting. Each patient must be reviewed on a case by case basis to determine medical necessity. This patient has gender identity disorder and is transitioning to a male. The patients age should not be used as a sole determinant for medical necessity. He has evidence of abnormal breasts for a male despite the use of hormonal therapy. The examination noted the patient has full female breasts with grade II ptosis. This medical condition would not likely resolve with continued hormonal therapy. Although this patient is a minor, chronological age is not as important as the level of pubertal development. In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate. All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral breast mastectomy is medically necessary for the treatment of this patients gender dysphoria. With regards to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure for a male body. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be performed to approximate a normal appearance. The patients breasts should be more consistent with male breasts. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. In this patients case, he has evidence of abnormal breasts for a male. The goal of the surgery is to create a more normal appearing male chest and offer a more than minimal improvement in the appearance of the patient. As such, in this patients case, bilateral breast mastectomy is reconstructive in nature.Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a liver single photon emission computed tomography (SPECT) scan for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  Contemporary noninvasive measurement of liver fibrosis is now made serologically and/or by elastography.  Having been supplanted by newer noninvasive liver probes, quantitative liver-spleen scanning is rarely used.  This modality is not standard of care in this clinical setting.  Therefore, the superior efficacy of a liver SPECT scan has not been established. Final Result: Two 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: All 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient was previously treated with methotrexate, which she did not tolerate, and prednisone.  Her current treatments include multiple topical steroids, topical Vitamin D analogues and a topical retinoid cream.  The Health Plan has required a trial and failure or contraindication to the use of two formulary preferred biologic medications.  This requirement is medically appropriate.  Given that there are no documented adverse reactions or contraindications to biologic therapy, Otezla is not medically indicated 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 dermatology 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 reintegration/reunification therapy. There is a lack of adequate data in current medical literature to support the use of reintegration/reunification therapy to prevent or treat major depressive disorder and anxiety. DAndrade describes reunification therapy as a form of family therapy that is often court-ordered when a parent-child contact problem has culminated in the child refusing to spend time with one parent. The American Psychiatric Association (APA) clinical practice guideline for the treatment of depression reports that there is insufficient evidence to recommend family therapy for the treatment of adults with major depressive disorder. In this case, this patient has a history of major depressive disorder. She has not responded to multiple medication trials and declines further medication trials. The patients provider has also referred the patient for transcranial magnetic stimulation. While repetitive transcranial magnetic stimulation is recommended for patients with major depressive disorder who have not responded to medications, the requested service is not medically indicated. Therefore, reintegration/reunification therapy 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 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: Upheld

This patient is a six-year-old male with a history of otitis media documented by his primary care provider on four occasions. The primary care physician has also documented normal hearing. Additional medical history includes a cyst underneath the tongue. The patient has been receiving speech therapy since May 2004. Over the last several months the patient and his therapist have been working on [R] sounds with only mild success. A request has been made for authorization and coverage for continued speech therapy. The Health Plan has denied this request indicating the requested services are not medically necessary.Although the primary care provider documented four bouts of otitis media over a seven-month period, the submitted documentation does not indicate whether this included effusion. March 2005 is the only time a transient loss of hearing is documented in the submitted records. Thus, there is insufficient evidence the patients delays are medical in nature. Furthermore, despite the June 2005 note from the speech therapist stating the patient made some gains in [R] sounds, there is little to indicate the patient has demonstrated significant gains. It appears limited progress has been made over the last six months. Moreover, the standardized tests performed show no deficits outside of the normal range. For these reasons, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.