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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1). Findings:  The physician reviewer found that  The records provided for review document that this patient has low back pain with radiation and instability. The records document that the patient has failed conservative care with physical therapy, epidural steroid injections, and radiofrequency ablation. The patients provider has recommended L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1. Reid and colleagues found statistically significant improvement in functional outcomes after lumbar fusion in patients with chronic low back pain with radiation. The authors reported that, Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The authors noted that candidates for lumbar fusion include patients who have degenerative changes and have failed conservative care. Hedlund and colleagues reported that the benefits of lumbar fusion are long-term, and the significant improvement compared to stand treatment persists for at least 12.8 years. Given these findings, the requested back surgery (L4 through S1 anterior lumbar instrumented interbody fusion and a posterior wide decompressive laminectomy, surgical reduction of spondylolisthesis and instrumented fusion from L4 through S1) 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female has requested repeat radiofrequency ablation for treatment of her chronic lumbar pain.  Findings:  The physician reviewer found that while the peer-reviewed medical literature demonstrates that radiofrequency nerve ablation can be efficacious for select patients, the medical necessity of repeat radiofrequency ablation is not supported in this patients case. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency ablation/denervation. The authors concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Consistent with these reports, it is appropriate to perform diagnostic lumbar facet blocks and quantify patient response prior to proceeding with lumbar facet denervation in order to determine whether the patient would remain a good candidate for the procedure. It is also appropriate to perform lumbar facet denervation for a patients back pain as long as lumbar facet arthropathy was proven to be a pathological cause either through physical examination and/or lumbar MRI with negative evidence for nerve root compression. As discussed above, while the majority of peer-reviewed literature supports the efficacy of radiofrequency ablation in the treatment of chronic spinal pain due to facet pathology, patients must be appropriately selected for the procedure. In this patients case, the submitted medical records document a negative response to the last lumbar radiofrequency ablation a little over four weeks prior to her presentation. Therefore, the patient is not an appropriate candidate for repeat radiofrequency ablation based upon the poor results of her most recent radiofrequency denervation procedure. There is no evidence that the patient is likely to derive greater benefit from the requested procedure than from other standard treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 4-year, 10-month-old male enrollee has requested applied behavioral analysis therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  Three physician reviewers found that the initial studies by Lovaas demonstrate the benefit of ABA therapy for patients with autism spectrum disorder. The research evidence for ABA is moderate to good, and is more reliable and reproducible than the research for many conditions which are not considered investigational. ABA is included in the standard treatment recommendations of most practitioners who treat patients in the early stages of autism. As the clinical research demonstrates, ABA is an integral part of an intensive approach for treating young patients with pervasive developmental disorder (PDD). Furthermore, the American Academy of Pediatrics supports ABA as effective treatment for pervasive developmental disorder and suggests early intervention.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee has requested surgical excision of pterygium, conjunctival graft and mytomycin C of the left eye for treatment of his pterygium.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the patient has bilateral recurrent pterygia with associated symptoms of pain, irritation, and blurred vision.  There is no evidence in the medical literature that non-surgical treatment is preferred for symptomatic recurrent pterygia.   It is well-established that recurrent pterygia can progress more quickly and aggressively than primary pterygia.  In situations where the visual axis is threatened, there is typically no alternative to surgical management.  In many other situations, the decision to proceed with surgery is based on other factors such as high astigmatism, restriction, atypical appearance, or pain.  All told, in this patients case, the requested surgical excision of pterygium, conjunctival graft and mytomycin C of the left eye are medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested a quarterly consultation with an endocrinologist for treatment of his diabetes.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  This patient is being treated with an insulin pump and continuous glucose monitor.  In this clinical setting, management by an endocrinologist is medically appropriate.  It is imperative that this patient avoid hypoglycemia.  Per the documentation, this patient has been monitored by an endocrinologist, with good diabetes control.  The best management of diabetes is anticipatory and preventive of complications.  In this patients case, the requested services with an endocrinologist will assist in maintaining good diabetes control.  In sum, the requested quarterly consultation with an endocrinologist is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. 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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested a PET/CT scan for an evaluation of his seminoma. Findings:  Two physician reviewers found that soft tissue abnormality will remain following 12 weeks of chemotherapy. However, a PET/CT scan will allow clinicians to estimate how much of the mass, if any, represents residual tumor. This assessment is possible by evaluating the remaining level of metabolic activity within the retroperitoneal mass, which is accomplished via PET/CT.  Thus, PET/CT scan is the most appropriate method to monitor this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Applying the American Society of Addiction Medicine (ASAM) guidelines for the treatment of patients with substance use disorders, this patient meets the criteria for IOP services. ASAM notes that the treatment of cannabis use disorder is particularly suited to IOP level of care services. Although IOP may not be indicated for a patient with generalized anxiety disorder or oppositional defiant disorder, this patient has a comorbid substance use disorder, which supports treatment at this level of care. The presence of a substance use disorder in the setting of anxiety and oppositional defiant disorder supports the need for IOP, in order to successfully manage and treat the patients cannabis use disorder. Further, the records document that the patient has been able to maintain sobriety and he has been working with a sponsor. All told, the IOP services were and are medically necessary for 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 with subspecialty certification in child and adolescent 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: The patient has requested authorization and coverage for Talicia 250-12.5-10 mg capsules. Chey and colleagues note that first-line treatment of Helicobacter pylori includes bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. The authors further note that if a patient fails a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options, while if a patient fails a first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. In this case, the patient has failed first-line treatments, and testing has found a resistance to clarithromycin. Given that guidelines recommend a rifabutin-based salvage regimen as the next treatment step in this clinical setting, the requested medication is medically indicated. Therefore, Talicia 250-12.5-10 mg capsules 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested a CT angiography for the evaluation of his potential coronary artery disease. Findings:  Three physician reviewers found that contrast enhanced CT coronary angiographies have been evaluated for a variety of coronary artery clinical problems. Advantages include its ability to depict the vessel wall and to characterize plaque. It is considered as sensitive as invasive angiography for evaluation of the left main coronary artery and the proximal left anterior descending artery. However, its sensitivity and specificity falls off for more distal vessels as well as the right coronary and circumflex arteries. Many of the studies reporting its usage present data on sensitivity and specificity only for vessels that were analyzable and not for all vessels studied. Other proposed usages include evaluation of bypass grafts, serial follow-up of invasive angiography, and evaluation of stents. CT coronary angiography may have problems identifying highly stenotic lesions. An area where it has shown promise is the identification of coronary artery anomalies.  In summary, while the noninvasive nature of CT coronary angiography makes it an attractive test, its exact role in the diagnostic algorithm of CAD remains to be undefined.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees stuttering.  Findings:  The physician reviewer found that this patient has struggled with intermittent dysfluency issues since three years of age.  Most recently, this has affected her school participation and social interactions.  Stuttering, or speech dysfluency, may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma.  Up to 80% of children who experience developmental dysfluency or mild pathologic dysfluency recover spontaneously.  However, a certain number of children deteriorate, developing severe dysfluency.  For this latter group, if therapy is started early, the prognosis is favorable.  While this patient does not demonstrate severe dysfluency at this time, her condition is affecting her social interactions and participation in public activities.  It is important to address this disorder now with speech therapy in order to improve the patients communication skills and prevent future difficulties.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested a Power Scooter with lighting package for the treatment of her condition. Findings:  The physician reviewer found that in the medical records submitted the physician reports support that the patient is ataxic and can move about two steps independently. She holds onto the bar of a scooter to transfer. It is reported she has had a scooter for over 30 years for indoor and outdoor use. The requested equipment is medically indicated for this patient.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services provided. The Health Plan has denied this request indicating that the services at issue were not emergency medical services. A review of the record indicates that the enrollee was evaluated by a plastic surgeon for bilateral congenital ear anomalies. Following evaluation, the enrollee proceeded to have EarWell devices placed bilaterally. The devices were replaced every two weeks, with follow-up treatments. The patient reponded well to the treatments without incident.In this case, the patient had a congenital deformity that was not addressed immediately. There is only a 3 month window to initiate EarWell System treatment in order to avoid future reconstructive surgery. Because of the limited treatment time, the evaluation of this infant was emergent, as was initiating and replacing the EarWell treatment. Treatment of the patients bilateral malformations of the ears was required to address and relieve serious dysfunction of a bodily part. Accordingly, the services at issue were necessary for treatment of an emergency medical condition, and the patient received emergency medical services. Final Result: The reviewer determined that the requested emergency 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 otolaryngology, and in plastic surgery within the head and neck 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:  The enrollee is requesting authorization and coverage for onabotulinumtoxinA (Botox) in conjunction with Aimovig. The enrollee has chronic migraines, intractable to multiple medications.  The enrollee reported partial response to the anti-calcitonin gene-related peptide (CGRP), Aimovig.  Enrollee began Aimovig at a dosage of 70mg, for a total of seven injections. The dosage was then increased to 140mg, which reduced headache frequency to two per week from an average of four per week. The enrollee has failed traditional migraine preventative options, including amitriptyline, Depakote, propranolol, venlafaxine, topiramate, gabapentin, and verapamil.  Headache frequency is currently at about five per month. The neurologist recommended the inclusion of Botox as an adjunctive therapy to Aimovig in order to provide a more aggressive treatment. The record indicates, while on Aimovig, the enrollees headache frequency decreased by half, which is generally considered an effective therapy in treating chronic migraines. Both Botox and Aimovig are FDA approved for use in the prophylaxis of chronic migraine headaches.  However, there is no published evidence in current medical literature to support the use of Botox with Aimovig, which has only been studied for use as monotherapy for the prophylaxis of migraine headaches.  Clinical trials of Aimovig have excluded participants from the phase II trial in chronic migraine if they had received Botox injections four months prior to the start of Aimovig therapy.  The provider indicated the enrollee will be receiving Botox while on Aimovig, as she had previously.  There are no completed studies with published results demonstrating the efficacy and safety of the Botox/Aimovig combination, or that the combination is more effective than the use of either agent alone or combined with an oral prophylactic agent. Therefore, the proposed treatment regimen cannot be expected to be more effective than any other treatment regimen for the prophylaxis of migraine.Final Result: Two 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 neurology 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: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for bevacizumab (Avastin) treatment of the enrollees lung cancer. Findings:  All Three physician reviewers found that The physician reviewer found there are currently no standard regimens for use in this patients clinical setting. However, Avastin has been shown to prolong survival in patients when given in combination with paclitaxel/carboplatin in first-line therapy (Sandler, et al). It has also been combined effectively with docetaxel or pemetrexed. As demonstrated by Herbst and colleagues, Avastin was combined with single agents and showed an advantage in terms of one year survival rates. Some recent abstracts presented at the American Society of Clinical Oncology also support other combinations with Avastin that show significant response. Thus, the providers recommended combination therapy including Avastin is appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. .Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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.